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Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Oncology Nutrition

Published:March 22, 2018DOI:https://doi.org/10.1016/j.jand.2018.01.012

      Abstract

      Oncology nutrition encompasses nutrition care for individuals along the cancer care continuum. Nutrition is a vital component of prevention, treatment, and healthy survivorship. The practice of an oncology registered dietitian nutritionist (RDN) reflects the setting and population served with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and organization’s activities. Provision of nutrition services in oncology requires that RDNs have advanced knowledge in the focus area of oncology nutrition. Thus, the Oncology Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice and Standards of Professional Performance as tools for RDNs currently in practice or interested in working in oncology nutrition, to address their current skill level and to identify areas for additional professional development in this practice area. The Standards of Practice address and apply the Nutrition Care Process and workflow elements, which are screening, assessment, diagnosis, intervention, evaluation/monitoring, and discharge planning and transitions of care. The Standards of Professional Performance consist of the following six domains of professionalism including: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements and describe three skill levels (competent, proficient, and expert) for RDNs working in oncology nutrition.
      Editor’s note: Figures 1 and 2 that accomplany this article are available online at www.jandonline.org.
      Approved September 2017 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Oncology Nutrition Dietetic Practice Group of the Academy. Scheduled review date: February 2024. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Oncology Nutrition may be addressed to Academy Quality Management staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, senior director, Quality Management at [email protected].
      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN). The two credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
      The Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Oncology Nutrition previously published in 2010.
      • Robien K.
      • Bechard L.
      • Elliott L.
      • Fox N.
      • Levin R.
      • Washburn S.
      American Dietetic Association: Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Oncology Nutrition Care.
      The revised documents, Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Oncology Nutrition, reflect advances in oncology nutrition practice during the past 7 years and replace the 2010 Standards. These documents build on the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics (Revised and approved Code of Ethics available in 2018),
      American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethics issues.
      along with the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and Revised 2017 Scope of Practice for the RDN,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information, see https://www.cdrnet.org/state-licensure-agency-list.
      The RDN’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the CDR RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required; or additional credentials (eg, Board Certified Specialist in Oncology Nutrition [CSO], Certified Nutrition Support Clinician [CNSC], Board Certified Specialist in Pediatrics [CSP], and Certified Case Manager [CCM]). The Scope of Practice Decision Tool (www.eatrightpro.org/scope), an online, interactive tool, guides an RDN through a series of questions to determine whether a particular activity is within his or her scope of practice. The tool is designed to assist an RDN to critically evaluate his or her personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics Scope of Practice Decision Tool: A self-assessment guide.
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services Hospital

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed January 10, 2018.

      and Critical Access Hospital

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed January 10, 2018.

      Conditions of Participation now allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips that outline the regulations and implementation steps for obtaining ordering privileges (https://www.eatrightpro.org/advocacy/legislation/all-legislation/therapeutic-diet-orders). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN(s) occurs in one of two ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges, or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be approved through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific processes.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II; Final rule (FR DOC #2014-10687; pp 27105-27157). http://www.gpo.gov:80/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf. Accessed January 10, 2018.

      The actual privileges granted will be based on the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      The Long-Term Care Final Rule published October 4, 2016 in the Federal Register, “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility’s policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final rule (FR DOC# F2016; pp 68688-68872)−Federal Register October 4, 2016; 81 (192): 68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed January 10, 2018.

      The qualified professional must be acting within the scope of practice as defined by state law; and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs who work in long-term care facilities should review the Academy’s updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (http://www.eatrightpro.org/quality). Review the state’s long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility’s processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (revisions are italicized and in red color).

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual−Appendix PP-Guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 Physician Services, §483.60 Food and Nutrition Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed January 10, 2018.

      CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107Appendicestoc.pdf.

      Academy Quality and Practice Resources

      The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of four standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      The SOPP consist of standards representing six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus area standards for RDNs in oncology nutrition provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering oncology nutrition and dietetic services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in general clinical practice with maintaining minimum competence in the focus area and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core SOP in Nutrition Care and SOPP for RDNs,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      the indicators (ie, measureable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in Oncology Nutrition were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Oncology Nutrition were reviewed and approved by the Executive Committee of the Oncology Nutrition Dietetic Practice Group and the Academy Quality Management Committee.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first two levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages his or her professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Oncology Nutrition. In Academy focus areas, the three levels of practice are represented as competent, proficient, and expert.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Oncology Nutrition.
      Standards of Practice are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (four separate standards) and the responsibilities for which registered dietitian nutritionists (RDNs) are accountable. The Standards of Practice (SOP) for RDNs in Oncology Nutrition presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional Performance (SOPP) for RDNs in Oncology Nutrition are authoritative statements that describe behavior in the professional role, including activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources (six separate standards).
      SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization by which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares his or her knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Tool, which is an online, interactive tool, is specifically designed to assist practitioners with this process.
      The term patient/client is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Patient/client could also mean client/patient, resident, participant, consumer, or any individual or group who receives oncology nutrition care and services. Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or any individual, group, or organization to which the RDN provides services. These services are provided to patients/clients of all ages. The Standards of Practice and Standards of Professional Performance are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of patient/clients of all ages, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean: Selecting from a range of best practice or evidence-based possibilities, one or more of which would give an acceptable result in the circumstances.
      Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcomes-focused statements against which a practitioner’s performance can be evaluated. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth.
      Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect three levels of practice (competent, proficient, and expert) for RDNs in oncology nutrition (see the image below). In addition, the core indicators have been expanded to reflect the unique competence expectations of the RDN in oncology nutrition.
      Standards described as proficient level of practice in this document are not equivalent to the Commission on Dietetic Registration certification, Board Certified as a Specialist in Oncology Nutrition (CSO). Rather, the CSO designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination, oncology nutrition knowledge, and application beyond the competent practitioner, and demonstrates, at a minimum, proficient-level skills. An RDN with a CSO designation is an example of an RDN who has demonstrated additional knowledge, skills, and experience in oncology nutrition by the attainment of a specialist credential and compliance with recertification requirements.

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning his or her practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that applies to all levels of practice.

      Academy of Nutrition and Dietetics. Definition of terms. http://www.eatrightpro.org/scope. Accessed January 10, 2018.

      A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.

      Academy of Nutrition and Dietetics. Definition of terms. http://www.eatrightpro.org/scope. Accessed January 10, 2018.

      A general practice RDN can include responsibilities across several areas of practice, including, but not limited to: community, clinical, consultation and business, research, education, and food and nutrition management. A new practitioner in oncology may utilize resources and seek out credentialed practitioners (eg, CSO, CSP, CNSC, CCM, oncology certified nurses, and oncology certified social workers) to add depth and breadth of their competence in oncology and responsibilities in oncology nutrition.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and consistently provides safe and reliable service; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice.

      Academy of Nutrition and Dietetics. Definition of terms. http://www.eatrightpro.org/scope. Accessed January 10, 2018.

      An RDN may have achieved the experience criteria and be eligible for certification as a Board Certified Specialist in Oncology (CSO) or Pediatrics (CSP), and/or another certification beneficial for practice (eg, CNSC) to demonstrate proficiency.

      Expert Practitioner

      An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify “what” is happening and “how” to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build upon nutrition and dietetics.

      Academy of Nutrition and Dietetics. Definition of terms. http://www.eatrightpro.org/scope. Accessed January 10, 2018.

      An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s). Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility.
      These Standards, along with the Academy/CDR Code of Ethics,
      American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethics issues.
      answer the questions: Why is an RDN uniquely qualified to provide oncology nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality oncology nutrition care and service at the competent, proficient, and expert levels?

      Overview

      Oncology: A branch of medicine addressing the prevention, diagnosis, and treatment of cancer. The cancer care continuum encompasses prevention, treatment, recovery from treatment, survivorship, living with cancer, and palliative/hospice care. An oncology RDN may practice in, but is not limited to, the following settings and disciplines: medical oncology, surgical oncology, radiation oncology, cancer prevention/wellness, hematology, hematopoietic stem cell transplantation, palliative care/hospice, and oncology nutrition-related research. An oncology RDN’s practice reflects the setting and populations served (eg, pediatrics or adults) with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and the organization’s activities (eg, research, case management, management of patients/clients receiving home nutrition support [enteral and/or parenteral nutrition]).
      Cancer is a complex, multifactorial disease state. While often thought of as one disease, there are more than 200 different types of cancer, each with its own etiology, set of potential treatment regimens, and likelihood of response to treatment. The American Cancer Society estimated that almost 1.7 million new cases of cancer would be diagnosed in the United States in 2017. Fortunately, advances in cancer screening, diagnosis, and treatment over the past 30 years have resulted in steady increases in the numbers of cancer survivors, with current overall 5-year survival rates of >66%.

      Howlander N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2013. National Cancer Institute Surveillance, Epidemiology, and End Results Program website. https://seer.cancer.gov/archive/csr/1975_2013/#contents. Published April 2016. Accessed January 10, 2018.

      However, 5-year survival rates range from 7% for pancreatic cancer to nearly 100% for in situ breast cancers.

      Howlander N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2013. National Cancer Institute Surveillance, Epidemiology, and End Results Program website. https://seer.cancer.gov/archive/csr/1975_2013/#contents. Published April 2016. Accessed January 10, 2018.

      The American Cancer Society estimates that 15.5 million cancer survivors were alive in the United States as of January 1, 2016. Diet modification and lifestyle interventions have been shown to be effective in decreasing the risk of cancer

      World Cancer Research Fund/American Institute for Cancer Research. Food, nutrition, physical activity, and the prevention of cancer: A global perspective. http://www.wcrf.org/sites/default/files/english.pdf. Published 2007. Accessed January 10, 2018.

      World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project: Cancer prevention & survival: Summary of global evidence on diet, weight, physical activity & what increases or decreases your risk of cancer. http://www.wcrf.org/sites/default/files/CUP-Summary-Report.pdf. Published July 2016. Accessed January 10, 2018.

      • Lei Q.
      • Zheng H.
      • Bi J.
      • et al.
      Whole grain intake reduces pancreatic cancer risk: A meta-analysis of observational studies.
      and in improving long-term outcomes for cancer survivors.
      • Schwedhelm C.
      • Boeing H.
      • Hoffmann G.
      • Aleksandrova K.
      • Schwingshackl L.
      Effect of diet on mortality and cancer recurrence among cancer survivors: A systematic review and meta-analysis of cohort studies.
      • Taborelli M.
      • Polesel J.
      • Parpinel M.
      • et al.
      Fruit and vegetables consumption is directly associated to survival after prostate cancer.
      RDNs working in oncology practice settings must develop the appropriate knowledge, skills, competencies, and judgment to competently provide safe and effective nutrition care across the cancer continuum (prevention, treatment, and survivorship). In 2007, the Academy of Nutrition and Dietetics (Academy) Evidence Analysis Library Expert Work Group, which included ON DPG members, published the Oncology Nutrition Evidence-Based Practice Guideline, which provides systematically developed statements based on the scientific evidence to assist practitioner and client decisions about appropriate oncology nutrition interventions during cancer treatment. In 2010, a new evidence analysis work group was formed to supplement the original Guideline, which was published in 2013. These resources are available to Academy members through the Evidence Analysis Library (www.andeal.org). In 2017, the Oncology Evidence-Based Nutrition Practice Guideline for Adults was published in the Journal of the Academy of Nutrition and Dietetics.
      • Thompson K.L.
      • Elliott L.
      • Fuchs-Tarlovsky V.
      • Levin R.M.
      • Coble Voss A.
      • Piemonte T.
      Oncology evidence-based nutrition practice guideline for adults.
      The ON DPG provides several resources for RDNs working in oncology. These include publication of several premier oncology nutrition resources, and development of the SOP and SOPP for RDNs in Oncology Nutrition. In 2015, the Pediatric Subunit of ON DPG was formed. Since that time, the members of the subunit have created three pediatric-specific webinars, published numerous articles on pediatric oncology topics in the ON DPG and the Pediatric Nutrition Practice Group newsletters, and expanded references available to pediatric RDNs in oncology.
      The ON DPG has collaborated on many oncology-related resources. Refer to Figure 4 for a comprehensive list of resources. An example is The Oncology Nutrition Handbook: Tools and Counseling Resources for Professionals, Second Edition, which has an expected 2018 release date, formerly The Complete Resource Kit for Oncology Nutrition. The handbook contains patient handouts and information for RDNs in the areas of clinical care and survivorship.

      Academy of Nutrition and Dietetics. Complete resource kit for oncology nutrition. http://www.oncologynutrition.org/store/product/the-complete-resource-kit-for-oncology-nutrition-162?returnBack=%2Fstore. Accessed January 10, 2018.

      The Oncology Nutrition for Clinical Practice book was published and serves as a comprehensive resource for RDNs working with oncology patients and those studying for the certification examination.
      Oncology Nutrition Dietetic Practice Group
      Oncology Nutrition for Clinical Practice.
      Figure 4Oncology nutrition resources (not all-inclusive).
      ResourceAddressDescription
      Academy of Nutrition and Dietetics (Academy) Complete Resource Kit for Oncology Nutritionwww.eatrightstore.org

      http://www.oncologynutrition.org/store
      This comprehensive, web-based resource, developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) encourages a proactive approach to symptom control and nutrition care of cancer patients. It includes a wealth of background information for the health care professional, counseling tips, dozens of recipes, and more than 50 patient education handouts on topics such as adopting a plant-based diet, nausea and vomiting, complementary and alternative therapies, and increasing fluid intake. Note: The second edition will publish in 2018 as The Oncology Nutrition Handbook: Tools and Counseling Resources for Professionals.
      Academy Oncology Evidence-Based Nutrition Practice Guidelinewww.andeal.org/oncThe Evidence Analysis Library is an online resource created by the Academy. It is a series of systematic reviews and evidence-based nutrition practice guidelines developed on a predefined approach and criteria. Meticulous methods are used to document each step to ensure objectivity, synthesis, and reproducibility of the process. Expert Work Group members evaluate, synthesize, and grade the strength of the evidence to support conclusions that answer a precise series of questions. Clinical practice guideline recommendations are systematically developed statements based on scientific evidence to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The Academy Oncology Evidence-Based Nutrition Practice Guideline for Adults was published in 2007, updated in 2013, and published in the Journal of the Academy of Nutrition and Dietetics in February 2017.
      • Thompson K.L.
      • Elliott L.
      • Fuchs-Tarlovsky V.
      • Levin R.M.
      • Coble Voss A.
      • Piemonte T.
      Oncology evidence-based nutrition practice guideline for adults.
      Academy Oncology Nutrition Dietetic Practice Group (ON DPG)www.oncologynutrition.orgThe ON DPG is a dietetic practice group of the Academy of Nutrition and Dietetics with more than 2,200 members. The mission of the ON DPG is to provide direction and leadership for quality oncology nutrition practice through education and research. An electronic mailing list for ON DPG members to network and share information related to oncology nutrition is also available.
      Academy Oncology Nutrition for Clinical Practicewww.oncologynutrition.orgPublished by Oncology Nutrition Dietetic Practice Group members, this book provides the most up-to-date oncology nutrition practice recommendations; latest nutrition assessment tools; and the knowledge and resources you need to take your oncology nutrition practice to the next level.
      Academy Pocket Guide to the Nutrition Care Process and Cancerhttps://www.eatrightstore.org/product-type/pocket-guides/academy-pocket-guide-to-the-nutrition-care-process-and-cancerThis guide integrates the Nutrition Care Process framework with the 2007 and 2013 Oncology Nutrition Evidence-Based Nutrition Practice Guidelines and other recommendations about medical nutrition therapy for patients diagnosed with cancer.
      American Institute for Cancer Research (AICR)/World Cancer Research Fund (WCRF) Continuous Update Project (CUP) Reportshttp://www.aicr.org/continuous-update-project/Systematic review of the literature and recommendations on diet, physical activity, and cancer prevention completed in 2007 by the WCRF and the AICR. CUP is an ongoing analysis of global scientific research into the link between diet, physical activity, weight, and cancer. CUP reports are published regularly to review and add evidence for specific cancer types.
      American Cancer Societywww.cancer.orgA nationwide, community-based voluntary health organization that is committed to fighting cancer through balanced programs of research, education, patient service, and advocacy.
      American Society for Parenteral and Enteral Nutrition (ASPEN)www.nutritioncare.orgASPEN is composed of health care professionals involved in research, clinical practice, advocacy, education, and an interdisciplinary approach to nutrition support therapy.
      Board Certification in Oncology Nutrition (Commission on Dietetic Registration [CDR])https://www.cdrnet.org/certifications/board-certified-specialistThe CDR grants Board Certification in Oncology Nutrition in recognition of an applicant's documented practice experience and successful completion of an objective examination in the specialty area. Individuals who successfully complete the board certification process are granted the Certified Specialist in Oncology Nutrition (CSO) credential, which provides potential employers, oncology patients, and caregivers with a tool to evaluate the expertise of the credentialed nutrition and dietetics practitioners providing oncology nutrition services.
      Cancer Program Standards, Commission on Cancerwww.facs.org/cancer/coc/programstandards.htmlStandards for the provision of cancer care by hospitals, treatment centers, and other facilities developed by the American College of Surgeons Commission on Cancer to ensure quality, multidisciplinary, and comprehensive cancer care delivery.
      Clinical Oncology Society of Australiawww.cosa.org.au/The Clinical Oncology Society of Australia is the peak national body representing health professionals from all disciplines whose work involves the care of cancer patients.
      European Prospective Investigation into Cancer and Nutrition (EPIC)http://epic.iarc.fr/The EPIC study investigates the relationships between diet, nutritional status, lifestyle, and environmental factors and the incidence of cancer.
      Examining Access to Nutrition Care in Outpatient Cancer Centers: Proceedings of a Workshophttps://www.nap.edu/read/23579/chapter/1National Academies of Sciences, Engineering, and Medicine’s Food and Nutrition Board convened a 1-day public workshop titled “Examining Access to Nutrition Care in Outpatient Cancer Centers,” to explore evolving interactions between nutritional care, cancer, and health outcomes.
      Multinational Association of Supportive Care in Cancer (MASCC)http://www.mascc.org/MASCC is an international multidisciplinary organization dedicated to research and education in all aspects of supportive care for people with cancer, regardless of the stage of their disease. Because supportive care encompasses all aspects of care, it involves a variety of disciplines and specialists, including registered dietitian nutritionists.
      National Cancer Databasewww.facs.org/quality%20programs/cancer/ncdbA database collecting cancer outcomes data from more than 1,500 Commission on Cancer−accredited facilities in the United States and Puerto Rico. A joint program of the Commission on Cancer and the American Cancer Society.
      National Cancer Institute (NCI)

      NCI Dictionary of Cancer Terms

      NCI Drug Dictionary
      www.cancer.gov

      www.cancer.gov/dictionary

      www.cancer.gov/drugdictionary
      The official website for the NCI, an institute of the National Institutes of Health.

      Includes more than 8,000 terms related to cancer and medicine.

      Contains definitions and synonyms for drugs/agents used to treat cancer or cancer-related conditions. Many entries include links to patient information and NCI's Physician Data Query Cancer Clinical Trials Registry.
      National Comprehensive Cancer Network (NCCN)www.nccn.orgA not-for-profit alliance of 26 cancer centers dedicated to improving quality and effectiveness of care provided to patients with cancer. Experts from NCCN institutions develop and maintain the NCCN Clinical Practice Guidelines.
      Surveillance, Epidemiology and End Results (SEER) programwww.seer.cancer.govThe SEER program of the NCI provides information on cancer statistics in the United States.
      The National Center for Complementary and Integrative Health (NCCIH)https://nccih.nih.gov/The NCCIH conducts, supports, and provides information about complementary health products and practices.
      CDR, assisted by members of the ON DPG, established a specialist certification in oncology nutrition, the Board Certified Specialist in Oncology Nutrition (CSO). The credential recognizes documented oncology practice experience and successful completion of an objective examination in the specialty area. There are currently approximately 800 CSOs who have successfully met the criteria for certification. Eligibility criteria for the specialist credential, application, and other information are available from CDR (www.cdrnet.org).
      Oncology RDNs work at community hospitals, academic medical centers, and outpatient cancer centers, National Institutes of Health: National Cancer Institute, state agencies, and universities. They are clinicians, managers, program directors, researchers, and educators who provide quality care, leadership, and contributions to the body of knowledge in oncology and oncology nutrition. Oncology RDNs may have autonomy in practice (ie, an ambulatory clinic may only employ one part-time clinician); precept nutrition and dietetics students/interns; mentor and serve as a oncology nutrition resource to other nutrition and dietetics practitioners (RDNs, Nutrition and Dietetics Technicians, Registered [NDTRs]) and members of the oncology interprofessional team; take part in interprofessional patient care rounds representing nutrition services; serve as a speaker on diet, nutrition, and cancer-related topics for community and professional audiences; routinely attend and contribute to the discussions at general or disease-specific Tumor Boards; or be designated as their institution’s RDN representative to the Cancer Committee in American College of Surgeons’ Commission on Cancer−accredited centers. In addition to working with clients and patients with cancer who are receiving treatment, oncology RDNs work with the public to bring awareness to lifestyle choices that may reduce the risk of cancer through outreach, classes, and support groups.
      In 2016, ON DPG members collaborated with the National Academy of Science and Medicine (formerly the Institute of Medicine) on the workshop “Examining Access to Nutrition Care in Outpatient Cancer Centers.”
      National Academies of Sciences, Engineering, and Medicine
      Examining Access to Nutrition Care in Outpatient Cancer Centers: Proceedings of a Workshop.
      Gaps were identified during the workshop. The first addressed was the lack of standard practice guidelines for nutritional services in the National Comprehensive Cancer Network guidelines. As a result, the ON DPG put forward to include with the 2017 National Comprehensive Cancer Network guidelines that “A registered dietitian should be part of the multidisciplinary team for treating patients with head and neck cancer throughout the continuum of care” and “nutrition evaluation should be carried out by a registered dietitian for patients with pancreatic cancer.” A second identified gap was the need to secure funding through the National Cancer Institute for Provocative Questions to address the question: Through what mechanism do diet and nutritional interventions affect the response to cancer treatment? The full report from the workshop and an informative infographic can be accessed from the ON DPG website (www.oncologynutrition.org).
      Working with oncology patients is challenging and rewarding. The many resources available for the RDN, including this SOP and SOPP, help guide new and experienced practitioners to assure quality care for patients and their families affected by cancer. The ON DPG continues to champion and support oncology nutrition practice through publications, evidence analyses, interagency collaboration, and research initiatives.

      Academy Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Oncology Nutrition

      An RDN can use the Academy Revised 2017 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Oncology Nutrition (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide oncology nutrition and dietetics care and services;
      • self-evaluate whether he or she has the appropriate knowledge, skills, and judgment to provide safe and effective oncology nutrition and dietetics care and service for their level of practice;
      • identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of oncology nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in oncology nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of oncology nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of oncology nutrition and dietetics care and services;
      • guide the development of oncology nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in oncology nutrition and dietetics, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in oncology nutrition is learning the principles that underpin this focus area and is developing knowledge and skills, and judgment for safe and effective oncology nutrition practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of oncology nutrition must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and available resources to support and ensure quality oncology-related nutrition and dietetics practice.
      At the proficient level, an RDN has developed a more in-depth understanding of oncology nutrition practice and is better equipped to adapt and apply evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations (eg, an oncology patient following prescribed nutrition therapy for non-oncologic comorbidities that may conflict with nutrition interventions for their oncologic diagnosis). The RDN at the proficient level may be a Board Certified Specialist in Oncology Nutrition (CSO).
      At the expert level, the RDN thinks critically about oncology nutrition and dietetics, demonstrates a more intuitive understanding of oncology nutrition and dietetics care and service, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the oncology nutrition RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of oncology nutrition and dietetics within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement oncology nutrition and dietetics services, they also manage, drive and direct clinical care; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of oncology nutrition and dietetics practice.
      Indicators for the SOP and SOPP for RDNs in Oncology Nutrition are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 SOP and 2 SOPP, available at www.jandonline.org). Within the SOP and SOPP for RDNs in Oncology Nutrition, an “X” in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in oncology nutrition could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide oncology care for patients/clients. An example of such a patient/client would be one with a new oncologic diagnosis who is preparing to start single modality treatment with chemotherapy.
      An “X” in the proficient column indicates that an RDN who performs at this level has a more in-depth understanding of oncology nutrition and dietetics and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations. This may be a patient/client who will be receiving multiple modalities of treatment requiring unique specialized nutrition interventions at each stage of the treatment continuum, for example, primary surgical resection followed by adjuvant chemotherapy and radiation.
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of oncology nutrition and dietetics and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge; skills; and behaviors, including leadership; vision; and credentials.
      Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and should apply to RDNs in all three levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an “X” is placed in all three levels of practice, it is understood that all RDNs in oncology nutrition are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in Oncology Nutrition is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in Oncology Nutrition at determined intervals to evaluate their individual focus-area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance. This self-appraisal also enables oncology nutrition RDNs to better utilize these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR’s updated system implemented with the 5-year recertification cycle that began in 2015 incorporates the use of essential practice competencies for determining professional development needs.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the new three-step process, the credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to the RDN’s area(s) of practice (essential practice competencies and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education over the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. For more information, see https://www.cdrnet.org/competencies-for-practitioners.
      RDNs are encouraged to pursue additional knowledge, skills, and training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by state law. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.
      • Gates G.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs should collaborate with other RDNs in oncology nutrition as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 5 for role examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in Oncology Nutrition.
      Figure 5Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Oncology Nutrition.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      Clinical practitioner, inpatient careThe hospital employing a registered dietitian nutritionist (RDN) in general clinical practice has changed the coverage assignment for the RDN to include patients receiving chemotherapy or admitted for management of treatment-related side effects in the inpatient medical oncology unit. The RDN reviews available resources regarding medical nutrition therapy for individuals receiving chemotherapy. The RDN recognizes a need for more in-depth knowledge and/or skills in treatment and management of individuals with cancer. The RDN reviews the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Oncology Nutrition to evaluate skills and competencies for providing care to individuals with cancer and sets goals to improve competency in this area of practice before providing care to this population independently.
      Clinical practitioner, ambulatory careAn RDN working in an ambulatory medical clinic notices an increase in the number of clients with cancer. The RDN recognizes limited experience with this diagnosis and reviews available medical and medical nutrition therapy resources to identify knowledge and skills for continuing education. The RDN uses the SOP and SOPP in Oncology Nutrition to evaluate expected outcomes and the level of competence needed to provide quality oncology nutrition care to these individuals. While expertise is developed, the RDN identifies mentors for consultation when patients have complex management needs beyond the RDN’s experience/level of competence.
      Clinical practitioner, outpatient cancer centerAn RDN working in an outpatient oncology center notices an increase in the number of patients being referred for nutrition consults after a malnutrition screening tool is instituted. The RDN refers to the SOP and SOPP in Oncology Nutrition to review indicators related to malnutrition and the hospital’s standards for nutrition assessments and identifying degree of malnutrition to consider in the assessment of these patients. As part of performance plan, the RDN looks specifically for continuing education activities focused on treatment of malnutrition-related side effects of cancer therapies.
      Clinical nutrition managerA hospital’s clinical nutrition manager (CNM) who oversees several RDNs providing nutrition care to patients/clients with cancer considers the SOP and SOPP when determining expertise needed at the program level, position descriptions, work assignments, and when assisting staff in evaluating competency and needs for additional knowledge and/or skills in oncology nutrition care. The CNM recognizes the SOP and SOPP as important tools for staff to use to assess competence in oncology nutrition care and to use when identifying personal performance plans.
      ResearcherAn RDN working in a research setting is awarded a grant to demonstrate the role of the RDN and the impact of nutrition interventions provided by an RDN on health outcomes of patients/clients with cancer. The RDN uses the SOP and SOPP in Oncology Nutrition in consultation with proficient and expert level oncology nutrition practitioners as a resource in designing the research protocol. The SOP and SOPP also serve as resources for identifying areas for staff development and/or collaboration with a colleague more experienced in oncology nutrition research.
      Nutrition and dietetics educatorThe educator designing continuing education materials for the RDN in oncology nutrition care develops tools (eg, handouts, presentations, workshops, social networking tools) to support use of the SOP and SOPP in Oncology Nutrition as a resource to guide practice. Before beginning work, the RDN uses the indicators in the SOP and SOPP to identify knowledge and skills to further develop; revises professional development plan; and seeks mentorship to identify appropriate continuing education activities. The RDN’s goal is to gain the needed focus area knowledge to develop the tools supporting the SOP and SOPP for Oncology Nutrition and to enhance career options within this focus area of practice.
      Telehealth practitionerAn RDN working in a telehealth setting who provides nutrition consultations to patients/clients with varied medical problems including cancer refers to the SOP and SOPP in Oncology Nutrition for resources, guidance for competent practice and when to consult with or refer patient/client to an RDN with more expertise in oncology nutrition. The RDN routinely monitors all relevant state laws and regulations, the Academy of Nutrition and Dietetics telehealth resources, and organization policies regarding the practice of telehealth specifically considering requirements if a patient/client lives in another state. As the number of patients/clients with cancer referred for nutrition counseling has increased, the RDN uses the SOP and SOPP in Oncology Nutrition to self-evaluate level of practice to determine areas to strengthen. The RDN consults with a colleague in another hospital who is a certified specialist in oncology (CSO) for mentoring and ideas for continuing education activities to enhance skills.
      In some instances, components of the SOP and SOPP for RDNs in Oncology Nutrition do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains the consensus of the content experts that the distinctions are subtle, captured in the knowledge; experience; and intuition demonstrated in the context of practice at the expert level, which combines dimensions of understanding; performance; and value as an integrated whole.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual oncology nutrition RDNs in practice settings and professional activities that enhance patient/client care and/or services, can be used to illustrate outstanding practice models.

      Future Directions

      The SOP and SOPP for RDNs in Oncology Nutrition are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the three practice levels in support of safe, effective, and quality practice in oncology nutrition remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers. In view of the increase in incidence of cancer and the growing number of survivors, the oncology nutrition profession must be poised to provide increased access to medical nutrition therapy across all stages of the cancer continuum, including prevention, treatment, and survivorship.

      Summary

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Academy/CDR Code of Ethics, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOP and SOPP for RDNs in Oncology Nutrition are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in daily practice who provide care to individuals with cancer to consistently improve and appropriately demonstrate competency and value as providers of safe, effective, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in oncology nutrition practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years. Current and future initiatives of the Academy, as well as advances in the oncology nutrition care and services, will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy and the ON DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the nutrition and dietetics practitioner. These standards are not intended for disciplinary actions, or determinations of negligence or misconduct. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

      Acknowledgements

      The author acknowledge SOP/SOPP chair, Jodie Greear, MS, RD, CSO, LDN, and Expert Member Reviewers: Kristy Gibbons, MS, DN, CSP, CSO, LDN, Rhone M. Levin, MEd, RDN, CSO, LD, Ana Paula Noronha Barrére, CDN, Karen Smith, MS, RD, LDN, FAND, and Nancy Sacs, MS, RD. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND, Dana Buelsing, MS, and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPPs.

      Author contributions

      All authors reviewed and commented on subsequent drafts of the manuscript. Each author contributed to editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.

      Supplementary Materials

      Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Oncology Nutrition. Note: The terms patient, client, customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation depending on the setting and the population receiving care or services.
      Standards of Practice for Registered Dietitian Nutritionists in Oncology Nutrition

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition and oncology
      Oncology: Oncology is a branch or of medicine addressing the prevention, diagnosis, and treatment of cancer. The cancer care continuum encompasses prevention, treatment, recovery from treatment, survivorship, living with cancer, and palliative/hospice care. An oncology RDN may practice in, but is not limited to, the following settings and disciplines: medical oncology, surgical oncology, radiation oncology, cancer prevention/wellness, hematology, hematopoietic stem cell transplantation, palliative care/hospice, and oncology nutrition-related research. An oncology RDN’s practice reflects the setting and populations served (eg, pediatrics or adults) with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and the organization’s activities (eg, research, case management, management of patients/clients receiving home nutrition support [enteral and/or parenteral nutrition]).
      nutrition-related problems.

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition assessment is conducted using validated tools based in evidence, the five domains of nutrition assessment, and comparative standards. Nutrition assessment may be performed via in-person, or facility/practitioner assessment application, or Health Insurance Portability and Accountability Act (HIPAA)−compliant video-conferencing telehealth platform.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Patient/client/population history: Assesses current and past information related to personal, medical, family, and psychosocial/social historyXXX
      1.1AAssesses primary cancer diagnosis and effect on ingestion, digestion, absorption, and utilization of nutrientsXXX
      1.1BAssess the impact of cancer treatment (eg, chemotherapy, radiation therapy, hematological stem cell transplantation) on the metabolism of nutrientsXXX
      1.1CAssesses history of treatment-related side effectsXX
      1.1C1Assess for latent health and disease conditions in cancer survivors and survivorship care plans related to previous cancer treatment (eg, diabetes, bone health, cardiovascular disease) and/or late-occurring side effects (eg, osteoradionecrosis, radiation enteritis, esophageal stenosis/fibrosis)XX
      1.1DAssesses cancer risk factors (eg, family history, smoking history, sun exposure, lifestyle factors, genetics, previous cancer treatment)XX
      1.1EAssesses the impact of disease on metabolism of nutrientsXX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index, waist circumference, and arm circumference), comparison to reference data (eg, percentile ranks/z-scores), and individual patterns and historyXXX
      1.2AEvaluates body composition using available diagnostic tools, such as hand-grip strength, arm anthropometry, or bioelectrical impedanceXX
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid−base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile), and medical tests and procedures (eg, gastrointestinal study, metabolic rate)XXX
      1.3AEvaluates laboratory data (eg, liver enzymes, white blood cell counts, tumor markers, inflammatory markers, micronutrient levels)XXX
      1.3BEvaluates the need for short-term dietary modifications in preparation for diagnostic tests (eg, glucose restriction before positron emission tomography scans, bowel preparation for colonoscopy), and therapeutic procedures (eg, nothing by mouth before surgery)XXX
      1.3CEvaluates for age-specific micro- and macronutrient needsXX
      1.3DUses results of diagnostic tests to evaluate nutritional status (eg, swallow evaluations, endoscopy, gastric-emptying studies)XX
      1.3EDetermines need for further testing based on findings, including appropriateness of tests and effects on the individual and the systemXX
      1.3FDistinguishes between alterations in nutritional status that may be a result of the cancer process and cancer treatment from those due to nutrient deficiency, and intervenes appropriately to address the underlying issueXX
      1.4Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect)XXX
      1.4AIncorporates screening for nutrition risk (eg, malnutrition, food security) using evidence-based screening tools for the setting and/or population (adult or pediatric)XXX
      1.4BAssesses for signs and symptoms of the cancer process and/or treatment-related complications (eg, mucositis, diarrhea cachexia, dysgeusia), and other nutrition impact symptomsXX
      1.4CAssesses for stages of cancer cachexia (signs of wasting; markers of inflammation; C-reactive protein)XX
      1.5Food and nutrition-related history assessment (ie, dietary assessment):

      Evaluates:
      XXX
      1.5AFood and nutrient intake, including the composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Considers past as well as present dietary intake, eating patterns and practicesXXX
      1.5A2Considers the individual’s stage of disease in the cancer continuum (ie, prevention, treatment and recovery, survivorship, living with cancer, hospice/palliative care) and/or comorbid conditions and impact on food intake and nutrient needsXXX
      1.5BFood and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Identifies current food and supplement intake, if applicable, challenges, and modifications made based on the individual’s stage in the cancer continuum and/or conditionsXX
      1.5B2Consults with home infusion company or home care provider regarding oral, enteral, parenteral, and/or hydration prescription, when applicableXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Considers safety and efficacy of dietary and dietary supplement intake (eg, macro- and micronutrients, fiber, bioactive substances, caffeine, herbals), and medical food/nutritional supplementsXXX
      1.5C2Consults interprofessional team on reporting adverse events to MedWatch, the US Food and Drug Administration Safety Information and Adverse Event Reporting ProgramXXX
      1.5C3Evaluates food/nutrient/supplement interactions with oncology treatments in conjunction with pharmacy servicesXXX
      1.5C4Evaluates nutrition-related impact of potential changes in medications or medication dose/schedules with the medical team to address symptom management, safety concerns, or appropriateness for the patient’s/client’s stage in the cancer continuumXX
      1.5C5Evaluates use, safety, and efficacy of integrative and functional medicinesXX
      1.5C5iAnalyzes current guidelines to make recommendations for use of alternative medications, and dietary supplementsXX
      1.5C5iiInvestigates drug−drug/botanical and drug−nutrient interactions in context of integrated disease state managementX
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, and readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Evaluates patient’s/client’s/advocate’s
      Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision-making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms12 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6).
      short-term and long-term goals for dietary intervention
      XXX
      1.5D2Evaluates behavioral mediators (or antecedents) related to dietary intake (ie, attitudes, self-efficacy, knowledge, intentions, readiness, and willingness to change, perceived social support, outside influences/caregiver influences on behavior, feelings about living with cancer)XXX
      1.5D3Evaluates ability to identify evidence-based information among resources found in media and popular literatureXXX
      1.5D4Evaluates self-care skills and behaviorsXXX
      1.5D5Evaluates lifestyle factors for the prevention of cancerXXX
      1.5D6Evaluates lifestyle factors for improving outcomes among cancer survivorsXX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related suppliesXXX
      1.5E1Assesses access to and use of community resourcesXXX
      1.5E2Assesses safe, healthful food/meal availability:
      • financial resources, access to farms, markets, and/or groceries; access to appropriate kitchen, pantry, and equipment for safely cooking, serving, and storing food)
      • awareness and use of federal, state, or local resources for food (eg, Supplemental Nutrition Assistance Program, food bank/pantries, shelters)
      • barriers to adequate food access (eg, homelessness, transportation, finances, language, and cultural differences)
      XXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental activities of daily living [IADLs]) (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Uses validated or commonly accepted developmental, functional, and mental status evaluation tools that consider cultural, ethnic, and lifestyle factors (eg, Karnofsky Performance Scale, Zubrod Score, Pediatric Quality of Life Inventory ADLs, National Cancer Institute’s Common Toxicity Criteria for Adverse Events)XX
      1.5F2Considers effect of planned treatment on usual activity level, ability to perform ADLsXX
      1.5F3Interprets changes in cognitive and/or physical functioning that affects ability to meet nutritional goalsXX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, and lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patternsXXX
      1.6AIdentifies the most appropriate reference data and/or standards (eg, international, national, state, institutional, and regulatory) based on practice setting and patient-/client-specific factors (eg, age and disease state)XXX
      1.6A1Uses reference standards for guidance (eg, Academy’s Adult and Pediatric Nutrition Care Manuals, Academy’s Pocket Guide to the Nutrition Care Process and Cancer, Complete Resource Kit for Oncology Nutrition, National Comprehensive Cancer Network [NCCN], Academy Oncology Nutrition Dietetic Practice Group www.oncologynutrition.org)XXX
      1.6BEvaluates nutrition-related cancer risk factors on a community level using data from population-based surveys (eg, Behavioral Risk Factor Surveillance System, National Health and Nutrition Examination Survey, Surveillance Epidemiology and End Results) to provide guidance for screening and assessmentX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7ACompares usual activity level to current age-appropriate physical activity guidelinesXXX
      1.7BAssesses adequacy of current level of physical activity to facilitate recovery and to decrease the risk of disease occurrence or disease recurrenceXX
      1.8Collects data and reviews data collected and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client, or staff for factors that affect nutrition and health statusXXX
      1.8AObtains and integrates data from members of the interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. nterprofessional could also mean interdisciplinary or multidisciplinary.
      team and other health care practitioners
      XX
      1.8BEvaluates the potential impact of the patient’s/client’s treatment plan (ie, chemotherapy, radiation, surgery, biologics, hormonal therapies, hematopoietic cell transplantation) on nutritional statusXX
      1.8B1Evaluates goal of treatment (curative vs palliative) as appropriate to nutrition assessmentXX
      1.8B2Evaluates type, frequency, duration of planned treatment as appropriate to nutrition assessmentXX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AReviews complications during active treatment for nutrition etiology or implications (eg, neutropenia, anemia, inadequate protein intake, inadequate energy intake, hyperglycemia, hyperlipidemia, hypertension, alterations in growth and development)XXX
      1.9BReviews chronic issues and late effects for nutrition etiology or implications (eg, neuropathy, cardiovascular complications, fatigue, anorexia, weight change, alterations in growth and development, alterations in bone health, recurrence of disease, change in activity)XX
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DPatient/client/population perceptions, values, and motivation related to presenting problemsXXX
      1.10EChanges in patient/client/population perceptions, values, and motivation related to presenting problemsXXX
      1.10FChanges in patient/client/caregiver level of understanding, food-related behaviors, and other outcomes for appropriate follow-upXXX
      1.10GReason for discharge/discontinuation or referral, if appropriate (eg, hospice, change in treatment goal)XXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures are used in valid and reliable ways
      • Appropriate and pertinent data are collected
      • Effective interviewing methods are used
      • Data are organized and categorized in a meaningful framework that relates to nutrition problems
      • Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
      • Problems that require consultation with or referral to another provider are recognized
      • Documentation and communication of assessment are complete, relevant, accurate, and timely
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is responsible for treating.

      Rationale:

      Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1AAnalyzes the assessment data to determine the impact of medical problems on the nutrition diagnosis(es)XXX
      2.1BIdentifies and labels the problemXXX
      2.1CDifferentiates between nutrition-related, cancer-related, and treatment-related side effectsXXX
      2.1DEvaluates multiple factors that impact nutrition diagnosis(es) to identify the major cause(s) likely to respond to medical nutrition therapyXX
      2.2Prioritizes the nutrition problems(s)/diagnosis(es) based on severity, safety, patient/client needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/ transitions of care needs, and patient/client/advocate perception of importanceXXX
      2.2APrioritizes nutrition diagnosis based on interpretation of current clinical status and goals of careXXX
      2.2BUses evidence-based protocols and guidelines to prioritize nutrition diagnoses in order of importance or urgency; seeks additional information, input if diagnoses are not typicalXXX
      2.2CUses experience, in addition to protocols and guidelines, to prioritize nutrition diagnoses in order of importanceXX
      2.2DSeeks collaborative information from proficient- or expert-level professionals when caring for patients/clients with complex needs (eg, more than two to three nutrition diagnoses)XX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriateXXX
      2.3AUses data from interview with patient/client/family members/advocate as appropriate to support nutrition diagnosis(es)XXX
      2.3BWorks with interprofessional team to verify medical/surgical diagnosis(es) and nutrition diagnosis(es) to determine priority order of nutrition diagnosis(es)XX
      2.4Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statement(s)] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statement(s)])XXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition Diagnostic Statements accurately describe the nutrition problem of the patient/client and/or community in a clear and concise way
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely
      • Documentation of nutrition diagnosis(es) is revised as additional assessment data become available
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to address nutrition-related behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention consists of two interrelated components—planning and implementation.
      • Planning involves prioritizing the nutrition diagnoses, conferring with the patient/client and others, reviewing practice guidelines, protocols, and policies, setting goals and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in condition and/or the patient/client/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of care is ultimately the responsibility of the RDN.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      Prioritization considerations may include:
      3.1AModifications based on the individual’s stage in the cancer continuum and/or conditionsXXX
      3.1BIntent of treatment (eg, curative, palliative, hospice)XXX
      3.1CPatient’s/client’s ability and willingness to implement and adhere to nutrition care planXXX
      3.1DAnticipation of acute/active (eg, mucositis, nausea), delayed/late emerging (eg, diarrhea, weight loss) or late effects of treatments (eg, malabsorption due to chronic radiation enteritis, growth failure, osteoporosis)XX
      3.1EComorbid diseases or conditions in the context of the individual’s current point in the cancer continuum (eg, obesity, diabetes, cardiovascular disease, congestive heart failure, hypertension, dyslipidemia, osteoporosis)XX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practices (eg, national guidelines, published research, Academy of Nutrition and Dietetics [Academy] Oncology Evidence Based Nutrition Practice Guideline, NCCN Clinical Practice Guidelines in Oncology, Complete Resource Kit for Oncology Nutrition, and databases)XXX
      3.2AEvaluates and selects appropriate guidelinesXXX
      3.2BRecognizes when it is appropriate to depart from established guidelines
      • for the comfort or benefit of the patient/client
      • to accommodate cultural differences
      XX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionalsXXX
      3.4AConfers with client, caregivers, and other health care providers to contribute to overall case managementXXX
      3.4BContributes knowledge of and recommendations for medical nutrition therapy to plan intervention in conjunction with the interprofessional teamXX
      3.4CFacilitates the collaborative process with interprofessional team members in planning the interventionX
      3.5Works with patient/client/advocate/population, and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.5ADevelops intervention plan to address current issues and educational needs (eg, nausea, vomiting, diarrhea, weight change)XXX
      3.5BDevelops expected outcomes in observable and measurable terms that are clear, concise, and reasonable for patient-/client-centered care and specific in relation to treatments and outcomesXXX
      3.5CConsiders options (short- and long-term) and develops the most appropriate regimen for the patient/clientXXX
      3.5DAnticipates potential complications of nutrition intervention (refeeding syndrome, enteral tolerance, regimen-related toxicities affecting food intake)XX
      3.5EPlans nutrition interventions with the goal of minimizing treatment-related side effects, treatment delays, and the need for emergency department visits or hospital admissionsXX
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6ADevelops the nutrition prescription based on nutrition assessment and nutrition diagnosis, treatment plan, goals and expected outcomesXXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7AIdentifies time and frequency of care based on individual needs, established goals and outcomes, and expected response to intervention(s)XX
      3.7A1Considers expected changes in nutritional status and progress toward nutrition outcomes (eg, growth/ developmental changes, changes in feeding mode)XX
      3.7A2Considers severity of nutritional issues and/or pending medical interventions that are influenced by or may influence nutrition statusXX
      3.7A3Develops guidelines for timing of intervention and follow-upX
      3.8Uses standardized terminology for describing interventionsXXX
      3.9Identifies resources and referrals needed (eg, psychosocial, financial assistance, educational resources, professional referrals [eg, speech therapy, physical therapy, occupational therapy])XXX
      3.9AIdentifies resources to assist patients/clients in using education services, and community programs appropriately (eg, support groups, health care services, meal programs, community outreach programs, recommended websites)XXX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10AFacilitates and fosters active communication, learning, partnerships, and collaboration with the oncology team and other consulting teamsXX
      3.10BIdentifies and seeks opportunities for external and interagency collaboration, specific to the individual’s/caregiver’s needsX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11AEnsures that patient/client and, as appropriate, family/significant others/caregivers, understand and can articulate goals and other relevant aspects of plan of careXXX
      3.11BEnsures communication of nutrition plan of care and transfer of nutrition-related data between care settings (eg, home health, acute care, ambulatory care, and/or long-term care facility) as neededXXX
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care (LTC) Regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10
      -driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diet, pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.12A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions, or supplemental water for enteral nutrition)XXX
      3.12A2iProvides education and counseling on the use of prescribed or recommended over-the- counter dietary supplements for safety, to minimize interactions with medications and treatmentsXX
      3.12A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12A3iSupervises RDNs in performing nutrition-related services when in a management roleXX
      3.12BUses appropriate behavior change theories (eg, motivational interviewing, behavior modification, modeling) to facilitate oncology nutrition interventionsXXX
      3.12CUses interpersonal, teaching, training, coaching, counseling, or technological approaches as appropriateXXX
      3.12DTailors nutrition intervention to the developmental stage of the patient/client and makes changes to the intervention as appropriateXX
      3.12EIdentifies or anticipates critical points in the oncology treatment process where nutrition interventions may contribute to positive treatment outcomesXX
      3.12FAnticipates potential for complications of the nutrition intervention or cancer treatment plan that would necessitate a change in the nutrition interventionXX
      3.12GDraws on experiential and evidence-based knowledge about the patient/client population to individualize the strategy for complex and dynamic interventionsX
      3.13Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organization policies/protocols, and applicable laws, and regulationsXXX
      3.13ASupervises professional, technical, and support personnelXXX
      3.14Continues data collectionXXX
      3.14AMonitors and analyzes clinical data to improve patient/client outcomesXXX
      3.14BConducts comprehensive data analysis to identify trends and update the plan of care accordinglyXX
      3.15Documents:
      3.15ADate and timeXXX
      3.15BSpecific treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DPatient/client/advocate/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPatient/client/advocate/caregiver/community comprehensionXXX
      3.15GBarriers to changeXXX
      3.15HOther information relevant to providing care and monitoring progress over time (eg, Survivorship Care Plan)XXX
      3.15IPlans for follow-up and frequency of careXXX
      3.15JRationale for discharge or referral if applicableXXX
      Examples of Outcomes for Standard 3: Nutrition Intervention
      • Goals and expected outcomes are appropriate and prioritized
      • Patient/client/advocate/population, caregivers, and interprofessional teams are involved in developing nutrition intervention/plan of care
      • Appropriate individualized patient-/client-centered nutrition intervention/plan of care, including nutrition prescription, is developed
      • Nutrition intervention/plan of care is delivered and actions are carried out as intended
      • Discharge planning/transitions of care needs are identified and addressed
      • Documentation of nutrition intervention/plan of care is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised.

      Rationale:

      Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality, patient-/client-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes; and intervenes when intervention/plan of care requires revision.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Identifies existing tools and methods to improve understanding of and/or adherence to plan as needed, based on the patient’s/client’s/family’s individual needs and situationXXX
      4.1A2Determines whether barriers to understanding are present and impacting the patient’s/client’s/caregiver’s compliance with the nutrition intervention/plan of careXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Collaborates with the interprofessional team to ensure patient/client understanding of the nutrition prescriptionXXX
      4.1B2Evaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.1CIdentifies critical points in the oncology treatment process or continuum of care for monitoring (eg, radiation dose received; chemotherapy cycle; surgery received/planned; post hematopoietic cell transplant period, or survivorship)XX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Quality of life (eg, ADLs; avoidance of nausea, vomiting, diarrhea, fatigue)XXX
      4.2A2Established oncology specific outcomes measures (eg, 5-year survival rate, Karnofsky Performance Scores) to relate nutrition outcomes to overall treatment outcomesXX
      4.2A3Physical well-being (eg, appropriate weight trend; fluid and electrolyte balance; maintain optimal bone density; decreasing risk of treatment-related side effects, disease recurrence or secondary malignancy)XX
      4.2A4Impact on short-term treatment outcome (eg, minimize treatment delays or withdrawals; minimize treatment-related side effects; minimize need for emergency department visits or hospital admissions)XX
      4.2A5Impact on long-term treatment outcomes (eg, relapse, survivorship)XX
      4.2A6Impact on the prevention of new cancers, late effects of treatment, and treatment-related comorbiditiesXX
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Evaluates intended effects and actual or potential adverse effects related to complex problems and interventions (late effects of treatment; radiation enteritis; chronic graft-vs-host disease)XX
      4.2B2Leads the development of protocols for timely review and documentation of patient’s/client’s clinical, metabolic, and nutrition status (including growth and development)X
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Consults with interprofessional team and other health care practitionersXXX
      4.3C2Identifies any potential changes to patient’s/client’s cognitive, physical, environmental status that could interfere with plan of careXX
      4.3C3Identifies problems beyond the scope of nutrition that are interfering with the intervention and recommends appropriate adjustmentsX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or statusXXX
      4.3ESupports conclusions with evidence (examples listed in indicators 4.2A1-A.2A6)XXX
      4.3E1Uses evidence-based standards to evaluate patient/client outcomes (eg, Academy Evidence Analysis Library for oncology nutrition)XXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4BModifies intervention as appropriate to address individual patient/client needs (eg, arranges for additional resources or more-intensive resources to fulfill the nutrition prescription; or adjusts tools and methods to ensure desired outcome)XX
      4.4CMakes adjustments in supportive services as needed (eg, training of direct providers, collaboration with health care professionals)XX
      4.4DDraws on experiential knowledge, clinical judgment, and research about the patient/client population to tailor the strategies in complicated, unpredictable, and dynamic situationsX
      4.5DocumentsXXX
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5FAdjustments to the nutrition intervention/plan of care, if indicatedXXX
      4.5GFuture plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, or dischargeXXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The patient/client/community outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Patient/client/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Health care utilization and cost-effectiveness outcomes (eg, change in medication, special procedures, planned/unplanned clinic visits, preventable hospital admissions, length of hospitalizations, prevented or delayed nursing home admissions, morbidity, and mortality)
      • Nutrition intervention/plan of care and documentation is revised, if indicated
      • Documentation of nutrition monitoring and evaluation is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and Timed
      a Oncology: Oncology is a branch or of medicine addressing the prevention, diagnosis, and treatment of cancer. The cancer care continuum encompasses prevention, treatment, recovery from treatment, survivorship, living with cancer, and palliative/hospice care. An oncology RDN may practice in, but is not limited to, the following settings and disciplines: medical oncology, surgical oncology, radiation oncology, cancer prevention/wellness, hematology, hematopoietic stem cell transplantation, palliative care/hospice, and oncology nutrition-related research. An oncology RDN’s practice reflects the setting and populations served (eg, pediatrics or adults) with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and the organization’s activities (eg, research, case management, management of patients/clients receiving home nutrition support [enteral and/or parenteral nutrition]).
      b Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision-making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms

      The Joint Commission. Glossary. In: Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: Joint Commission Resources; 2017.

      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed January 10, 2018.

      ).
      c Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. nterprofessional could also mean interdisciplinary or multidisciplinary.
      d Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed January 10, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed January 10, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care (LTC) Regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final rule (FR DOC# F2016; pp 68688-68872)−Federal Register October 4, 2016; 81 (192): 68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed January 10, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual−Appendix PP-Guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 Physician Services, §483.60 Food and Nutrition Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed January 10, 2018.

      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Oncology Nutrition. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient, client/patient/customer, family, participant, consumer, or any individual, group, or organization to which the RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Oncology Nutrition

      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to his/her area(s) of practice (eg, Health Insurance Portability and Accountability Act [HIPAA], state/local food safety regulations)XXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AComplies with applicable state licensure or certification laws and regulations including telehealthXXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement, Centers for Medicare and Medicaid Services Quality Indicators, American College of Surgeon’s [ACoS] Commission on Cancer, National Comprehensive Cancer Network [NCCN]) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AParticipates in hospital/agency/organization quality monitoring endeavors and advocates for oncology
      Oncology: Oncology is a branch or of medicine addressing the prevention, diagnosis, and treatment of cancer. The cancer care continuum encompasses prevention, treatment, recovery from treatment, survivorship, living with cancer, palliative/hospice care. An oncology RDN may practice in, but is not limited to, the following settings and disciplines: medical oncology, surgical oncology, radiation oncology, cancer prevention/wellness, hematology, hematopoietic stem cell transplant, palliative care/hospice, and oncology nutrition-related research. An oncology RDN’s practice reflects the setting and populations served (eg, pediatrics or adults) with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and the organization’s activities (eg, research, case management, management of patients/clients receiving home nutrition support [enteral and/or parenteral nutrition]).
      nutrition services
      XX
      1.4BLeads efforts to maximize oncology nutrition management services using national quality and safety dataXX
      1.4CAnticipates changes to local, state, and national quality initiatives, and leads efforts to support oncology nutrition and related servicesX
      1.4DLeads performance-improvement initiatives to ensure national quality and safety guidelines are in place to facilitate improved outcomesX
      1.5Uses a systematic performance-improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AEvaluates and ensures safe nutrition care delivery using organization/department-specified process or performance improvement modelXXX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Participates in interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary
      efforts to improve oncology outcomes
      XXX
      1.6A2Collaborates on interprofessional efforts to address or improve oncology outcomesXX
      1.6A3Leads interprofessional efforts to establish and improve oncology nutrition care interventions and outcomesX
      1.6BDefines expected outcomesXXX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Collects and documents nationally standardized and consensus-based oncology performance measuresXXX
      1.6C2Participates in or selects criteria for data collection specific to population (eg, demographics, including acuity, recognized clinical risk factors, morbidity, and mortality data) and setting as part of a quality-improvement processXXX
      1.6C3Serves in leadership role to evaluate benchmarks of cancer and nutrition-related program indicators compared to federal, state, and local public health and population based indicators (eg, Healthy People 2020 Leading Health Indicators, Health Effectiveness Data and Information Set, and national oncology quality-improvement measure sets) to improve outcomes and positively impact program planning and developmentX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Uses systematic processes and tools to collect and analyze the data; seeks assistance as neededXXX
      1.6D2Develops systematic processes and tools to collect, monitor, and analyze the data against expected outcomes (eg, outcomes data-collection tools available in the Academy Complete Resource Guide for Oncology)XX
      1.6D3Selects criteria for data collection, and advocates for and participates in the development of data-collection tools (eg, clinical, operational, and financial)XX
      1.6D4Develops and/or uses systematic process to collect and analyze oncology-related pooled data as part of an interprofessional or interorganization quality improvement process to improve outcomes and quality of careX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of patients/clients with or at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6FDocuments outcomes and patient reported outcomes (eg, PROMIS
      PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Reports outcomes to appropriate individuals and groupsXXX
      1.6F2Uses appropriate data-collection tools to collect, document, analyze, and share (with appropriate institutional approval) outcomes dataXX
      1.6F3Leads or collaborates in organization-approved efforts to share process and outcomes data with the cancer communityX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6HPublishes outcomes data (with appropriate institutional approval) in the scientific literatureXX
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7AUses systems to monitor problematic product names and error-prevention recommendations provided by Institute for Safe Medication Practices, US Food and Drug Administration, and United States Pharmacopeia in collaboration with interprofessional teamXXX
      1.7BContributes to awareness of potential drug−food or nutrient and drug−dietary supplement interactions and potential interactions between scheduled treatments and integrative and functional therapies (eg, grapefruit and paclitaxel [Taxol; Bristol-Myers Squibb Oncology]), green tea and bortezomib [Velcade; Millenium Pharmaceuticals, Inc]).XXX
      1.7CDevelops systems to monitor problematic product names and error prevention recommendations provided by Institute for Safe Medication Practices, US Food and Drug Administration, and United States PharmacopiaXX
      1.7DDevelops systems to alert oncology patients/clients and care providers to potential hazards (eg, foodborne illness outbreaks)XX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8A1Develops report of individual and departmental/ organizational outcomes and improvement recommendations and disseminates findingsXX
      1.8A2Develops report and disseminates findings of outcomes and improvement recommendations at quarterly meeting of Cancer Committee when the designated nutrition services representative in an accredited ACoS Commission on Cancer institutionXX
      1.8BCompares individual performance to self-directed goals and expected outcomes toward achieving program/service outcomesXXX
      1.8CCompares departmental/organizational performance to goals and expected outcomesXX
      1.8DBenchmarks departmental/organizational performance with national programs and standardsX
      1.9Evaluates interventions and workflow process (es) and identifies service and delivery improvementsXXX
      1.9AUses a continuous quality-improvement approach to measure performance against desired outcomes using data from multiple sourcesXXX
      1.9BDesigns and conducts audits to quantify the success of interventionsXX
      1.9CEvaluates the provision of oncology nutrition services, including patient/client census, reimbursement data, and customer satisfaction survey resultsXX
      1.10Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goalsXXX
      1.10AAdjusts services based on data and review of most current evidence-based information (eg, Oncology Evidence Based Nutrition Practice Guideline, NCCN guidelines); seeks assistance as neededXXX
      1.10BDevelops or contributes to implementation strategies for quality improvement tailored to the needs of the organization and patient/client populations (eg, identification/adaptation of evidence-based practice guidelines/protocols, skills training/ reinforcement, organizational incentives and supports)XX
      1.10CTrains and guides interprofessional performance improvement activities across organizationX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in customer-centered services
      • Performance improvement program specific to program(s)/service(s) is established and updated as needed; is evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other team members
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of practice
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safe, quality practice and services.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-centered service.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)XXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area(s) SOP SOPP into practice (www.eatrightpro.org/sop)XXX
      2.2BUses Revised 2017 SOP and SOPP in Oncology Nutrition and others as practice guides for professional roleXXX
      2.2CCrafts corporate/institutional policy, guidelines, human resource materials (eg, career ladders, acceptable performance level) using Academy focus area SOP and SOPP as guides when in a management roleXX
      2.2DDevelops and defines approach to practice in the field of oncology nutrition, and contributes to revisions of SOP and SOPP in Oncology Nutrition as practice evolvesX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ACompiles and submits evidence of practice (eg, chart notes and other deliverables) for review per organizational policy consistent with level of practice and performance expectationsXXX
      2.3A1Reviews submitted evidence of practice and provides feedback to employee under reviewXX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BFosters excellence and exhibits professionalism in oncology nutrition practice (eg, manages change effectively; demonstrates assertiveness, listening and conflict resolution skills; demonstrates ability to build coalitions)XXX
      2.4CLeads by example; exemplifies professional integrity as a leader of oncology nutrition by serving as a resource for evidence-based practice in oncology nutrition and educating fellow members of the interprofessional team/organizationXX
      2.4DDirects and develops policies that ensure accountability as applicable to a management roleX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional development (eg, feedback from peers, feedback from other health care professionals, feedback from clients, comparison to SOP and SOPP indicators, and/or the Oncology Nutrition Content Outline/Test Specifications provided with the Certified Specialist in Oncology [CSO] credentialing examination review materials)XXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])XXX
      2.6A1Documents professional development activities per CDR guidelines and organization’s requirementsXXX
      2.6A2Actively pursues oncology continuing education opportunities locally, regionally, and nationallyXXX
      2.6A3Develops and implements a plan for achieving the knowledge, skills, and experience needed to qualify for CSO certification, or others (eg, Board Certified Specialist in Pediatrics [CSP], Certified Nutrition Support Clinician [CSNC], Advanced Practice RDN [RDN-AP]) to support role and responsibilitiesXXX
      2.6A4Develops and implements plan for maintaining CSO certification, or others and proficient practice level applicable to setting, and role and responsibilitiesXX
      2.6A5Develops and implements a plan for achieving and maintaining expert practice for the majority of Oncology Nutrition SOP and/or SOPP indicators applicable to role and responsibilitiesX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AAccesses and utilizes/monitors major oncology care and education publicationsXXX
      2.7BDevelops skill in accessing and critically analyzing researchXX
      2.7CMentors others in developing skills in accessing and critically analyzing research for application to practiceX
      2.7DTranslates research into actionable items and recommendations for consumers to incorporate in their daily lifeX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AParticipates in peer evaluation, including but not limited to peer supervision, clinical chart review, professional practice, and performance evaluations, as applicableXXX
      2.8BParticipates in scholarly review, including but not limited to oncology professional articles, chapters, booksXXX
      2.8CServes as reviewer or editorial board associate for oncology professional organizations, journals, and booksXX
      2.8DLeads an editorial board for scholarly review, including but not limited to oncology professional articles, chapters, booksX
      2.9Mentors and/or precepts othersXXX
      2.9AParticipates in mentoring entry-level oncology nutrition professionals and serves as a preceptor for nutrition and dietetics students/interns; seeks guidance as neededXXX
      2.9BDevelops mentoring or internship opportunities for nutrition and dietetics practitioners, and mentoring opportunities for oncology and health care professionalsXX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice settingXXX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • Scope of Practice, Standards of Practice, and Standards of Professional Performance
        • Evidence-based practice and best practices
        • CDR Essential Practice Competencies and Performance Indicators
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and backgrounds
      • Competence is demonstrated and documented
      • Services provided are safe and customer-centered
      • Self-evaluations are conducted regularly to reflect commitment to lifelong learning and professional development and engagement
      • Professional development needs are identified and pursued
      • Directed learning is demonstrated
      • Relevant opportunities (education, training, credentials, certifications) are pursued to advance practice
      • CDR recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations and needs, and the mission, vision, principles, and values of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the RDN’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s)XXX
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Designs, provides justification, promotes, and seeks executive commitment to new services that will meet organization or institutional goals for oncology servicesXX
      3.1A2Leads in business and strategic planning at the interprofessional team/oncology program/organization level for development of appropriate products and services to meet unmet needsX
      3.1A3Leads long-term thinking and planning; anticipates needs; understands strategic plans, and integrates justification into plansX
      3.1BUses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service developmentXXX
      3.1B1Develops oncology nutrition services and programs to accommodate patient/client needs and lifestyles with consideration of, and input from, caregivers when appropriateXX
      3.1B2Synthesizes the results and outcomes of the services and programs to create new and unique offerings to meet patient/client and caregiver needsX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Designs and evaluates marketing strategies for RDN services; collects and utilizes benchmarking data for staffing resourcesXX
      3.1C2Advocates for staffing that supports the oncology patient/client population, census, programs and services, and goalsXX
      3.1C3Evaluates program/service data and scientific evidence to apply knowledge and skills to determine the most appropriate action plan for programs and servicesXX
      3.1C4Synthesizes and applies knowledge, skills, and experience at the expert level to analyze data from multiple sources to determine the most appropriate action plan to guide organization’s oncology nutrition programs and servicesX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Adapts practices to minimize or eliminate health disparities associated with culture, race, sex, socioeconomic status, age, and other factorsXXX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Receives referrals for services from and makes referrals to other nutrition professionals to address identified patient/ client/caregiver needsXXX
      3.2A2Promotes role and value of referring to certified oncology RDNs with the interprofessional team and in community outreachXX
      3.2A3Directs and manages referral processes and systemsX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practice (eg, nurses, speech language pathologists, social workers, case managers, physicians, and other providers)XXX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Documents sources of referrals to monitor effectiveness (ie, appropriate, timely) and modifies referral tools/ systems in collaboration with others as neededXX
      3.2C2Leads interprofessional team to identify appropriate changes to existing referral systems or to create new onesX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Applies patient/client/population values, goals, and needs to the design and delivery of oncology nutrition servicesXX
      3.3A2Facilitates discussions and development of tools to gather data on patient/client population to guide and justify oncology nutrition services (eg, population characteristics, diagnoses, service needs, transition of care needs/ concerns)X
      3.3BUses knowledge of the customer’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Adapts program/service practices to meet the needs of an ethnically and culturally diverse oncology populationXXX
      3.3B2Develops a listing of established resources and services within the specific ethnic/cultural community(ies) to recommend to patients/clients/familiesXX
      3.3B3Searches for additional patient/client population resources to help with health-related decision making to positively influence oncology nutrition outcomes within the patient/ client population’s specific ethnic/cultural community(ies), and collaborates as appropriateX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Understands behavior change and counseling theories (eg, health belief model; social cognitive theory/social learning theory; stages of change [transtheoretical theory]; Enabling/Access Enhancing [PRECEDE model]; Fishbein/Ajzen [theory of reasoned action]) and is able to apply theories in practiceXXX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Evaluates effectiveness in using different theoretical frameworks for interventions with oncology patients/ clientsXX
      3.3D2Directs efforts to improve collaboration between patients/ clients and other care providersX
      3.3EInvolves customers in decision makingXXX
      3.3E1Designs oncology nutrition therapy guidelines and services according to patient/client population needs and lifestyle with consideration of and input from caregivers when appropriateXXX
      3.3E2Facilitates patients’/clients’/families’ participation in health care decision making and goal settingXX
      3.4Executes programs/services in an organized, collaborative, cost-effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teamsXXX
      3.4A1Works within the traditional interprofessional team for education/skill development and to demonstrate role of RDN and nutrition in care of individuals with cancerXXX
      3.4A2Reports in partnership with health care providers, local health care system and referral sources to support/plan for treatment-related care, services, and education, including Survivorship Care Plan developmentXXX
      3.4A3Serves in consultant role for medical management of cancer and comorbiditiesXX
      3.4A4Plans, develops, and facilitates interprofessional process for implementation of systems/programs of oncology nutrition care and servicesX
      3.4BUses and participates in or leads in the selection, design, execution, and evaluation of customer programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management)XXX
      3.4B1Uses, collaborates on, or develops process for nutrition screening in the oncology population using evidenced-based screening tools for the oncology population; refer to Academy Oncology Evidence-Based Nutrition Practice Guideline
      • Thompson K.L.
      • Elliott L.
      • Fuchs-Tarlovsky V.
      • Levin R.M.
      • Coble Voss A.
      • Piemonte T.
      Oncology evidence-based nutrition practice guideline for adults.
      XX
      3.4B2Monitors and evaluates the effectiveness of oncology nutrition screening (eg, Malnutrition Screening Tool [MST]) and assessment (eg, Patient-Generated Subjective Global Assessment [PG-SGA]) tools; refer to Academy Oncology Evidence-Based Nutrition Practice Guideline
      • Thompson K.L.
      • Elliott L.
      • Fuchs-Tarlovsky V.
      • Levin R.M.
      • Coble Voss A.
      • Piemonte T.
      Oncology evidence-based nutrition practice guideline for adults.
      XX
      3.4B3Develops and manages oncology programs and services in compliance with national guidelines and standards (eg, Academy Oncology Evidence-Based Nutrition Practice Guidelines, ACoS Commission on Cancer Program Standards, NCCN Clinical Practice Guidelines in Oncology, World Cancer Research Fund/American Institute for Cancer Research: Food, Nutrition, Physical Activity, and the Prevention of Cancer report and recommendations for cancer prevention)XX
      3.4B4Plans and develops or collaborates on oncology community-based health promotion/prevention programs based on patient/client/population needs, culture, use of evidence-based strategies, and available resources, as applicable; and incorporating behavior change theory, self-concept, lifestyle functions, evaluation of learningXX
      3.4B5Analyzes, documents, and reports data from oncology nutrition screening auditsXX
      3.4B6Establishes administratively sound evidence-based programs (eg, cancer prevention, oncology education, survivorship program, and medical nutrition therapy services)X
      3.4B7Leads team on program review, identifying changes, and process revisions as neededX
      3.4CUses and develops or contributes to selection, design, and maintenance of policies, procedures (eg, discharge planning/ transitions of care), protocols, standards of care, technology resources (eg, HIPAA-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Uses evidence-based guidelines, best practices, and national and international guidelines in the delivery of oncology nutrition servicesXXX
      3.4C2Participates in development and updating of policies, procedures, protocols, and evidence-based practice tools applicable to settingXXX
      3.4C3Develops oncology nutrition programs, protocols, and policies based on current research, evidence-based guidelines, best practices, trends, and national and international guidelinesXX
      3.4C4Translates research findings into the development of policies, procedures, protocols, and guidelines for oncology nutrition careX
      3.4C5Leads process of developing, monitoring, and evaluating the use of policies/protocols/guidelines/practice tools for oncology nutrition programs based on evidence-based national and international guidelines, best practices, trends, national and organization goals and expectation; and plans and manages changesX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff
      Medical staff: Medical staff is composed of doctors of medicine or osteopathy and can, in accordance with state law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.6
      or medical director (eg, post-acute care settings, dialysis center, public health, community, free-standing clinic settings), consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10
      -driven delegated orders or protocols, initiating, or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iContributes to organization/medical staff process for identifying RDN privilege options to support oncology nutrition care and services (eg, feeding tube placement; diet orders; liquid nutritional supplements and modular products; vitamin and mineral supplements; enteral and parenteral nutrition orders)XX
      3.4D1iiNegotiates and/or establishes privileges at the organization or systems level for new advances in practiceX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies) and indirect calorimetry measurementsXXX
      3.4D3Establishes collaborative practice with other health care providers at organization or systems level (eg, a disease management program, case management)X
      3.4EComplies with established billing regulations, organization policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practicesXXX
      3.4FCommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s personal health informationXXX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to patients/clients, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5BSupervises professional, technical, and support personnel (eg, nutrition and dietetics technician, registered)XXX
      3.5B1Trains professional, technical, and support personnel, and evaluates and documents their competenceXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      3.6ACollaborates in or leads the designs of food delivery systems to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (ie, health care patients/clients, employee groups, visitors to retail venues schools, child and adult day-care centers, community feeding sites, farm to institution initiatives, local food banks)XXX
      3.6A1Collects data and offers feedback on current food/formula delivery systems reflecting needs and input of the oncology populationXXX
      3.6A2Collaborates in the design, evaluation, and/or revision of food delivery systems and other nutrition-related services (eg, food-safety considerations related to food preparation, holding, and delivery) for specific oncology populationsXX
      3.6A3Leads the design, evaluation, and/or revision of food-delivery systems and nutrition-related services and consults on food-delivery systems for specific oncology populations at the systems levelX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state or funding source regulations or guidelinesXXX
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems for target population(s)XXX
      3.6C1Provides guidance regarding products and formulas in accordance with best practices (eg, American Society for Parenteral and Enteral Nutrition guidelines)XXX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems including electronic health recordsXXX
      3.7A1Uses and participates in the development/revision of electronic health records applicable to settingXXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops or collaborates with the interprofessional team to capture oncology-specific data through electronic health records or other data-collection toolsXX
      3.7B2Contributes nutrition-related expertise to national cancer-related bioinformatics projects as needed (eg, National Cancer Institutes’ Cancer Bioinformatics Grid project)X
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services) and provide justification for maintenance or expansion of servicesXXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Prepares and presents reports for organization and accrediting bodiesXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy makers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Interacts with policy makers and insurers to contribute and influence oncology nutrition issuesXXX
      3.8A2Advocates for cancer prevention and cancer care services at the local, state, and federal policy level; and promotes public policy that influences provision of cancer care and services by participating in legislative and policy-making activitiesXXX
      3.8A3Works to introduce or collaborate on policy/law to facilitate oncology nutrition care across the cancer continuum (from prevention to survivorship)XX
      3.8A4Takes leadership role in cancer advocacy activities/issues; authors articles and deliver presentations on topic; networks with other cancer advocacy interested partiesX
      3.8A5Acts as an expert to law, policy makers, and insurers for oncology nutrition issuesX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Assesses client population for situations where cancer advocacy is neededXX
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action, establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates)XXX
      3.8DParticipates in cancer advocacy activities (eg, community cancer screenings, local American Cancer Society events), support groups, and community efforts to address needs of individuals with cancerXXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, and values, and customer needs and expectations
      • Customers participate in establishing program/service goals and customer-focused action plans and/or nutrition interventions (eg, in-person or via telehealth)
      • Customer-centered needs and preferences are met
      • Customers are satisfied with services and products
      • Customers have access to food assistance
      • Customers have access to food and nutrition services
      • Foodservice system incorporates sustainability practices addressing energy and water use, and waste management
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Professional, technical, and support personnel are supervised when providing nutrition care to customers
      • Ethical and transparent financial management and billing practices are used per role and setting
      Standard 4: Application of Research

      The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodologyXXX
      4.1BUses and encourages the use of evidence-based tools and/or resources as a basis for stimulating awareness and integration of current evidence, especially the Academy Oncology Evidence-Based Nutrition Practice GuidelinesXXX
      4.1CIdentifies pertinent nutrition-related clinical trial information (eg, National Cancer Institute resources) for application to patient/client careXX
      4.1DUnderstands study outcomes and how to interpret and apply the results to oncology clinical practiceXX
      4.1EIdentifies key clinical and management questions and utilizes systematic methods to extract evidence-based research to answer questions (suggested resource: Academy’s Evidence Analysis Manual)XX
      4.1FIdentifies key questions in clinical decision making, extracts research, and adjusts practice based on strength of this evidenceXX
      4.1GFunctions as a primary or senior author or reviewer of research and organization position papers, and other scholarly workX
      4.2Uses the best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2ASystematically reviews the available scientific literature in situations where evidence-based practice guidelines for oncology nutrition do not existXX
      4.2BInterprets the strengths and weaknesses of research findings from a single study in light of the more comprehensive research base on a given topicXX
      4.2CMentors others in applying evidence-based research and guidelines to practice (eg, considers the full breadth of research and other literature about best practices to recognize oncology as a complex, multifactorial disease state affecting multiple body systems)X
      4.3Integrates the best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to extend research to practice through journal clubs, professional supervision, and the Academy’s Dietetics Practice-Based Research NetworkXXX
      4.4BParticipates in oncology nutrition research, and applies the findings to professional practice, as appropriateXXX
      4.4CParticipates in design and/or implementation and reporting of practice-based researchXX
      4.4DIdentifies and initiates research relevant to oncology practice as the primary investigator or as a collaborator with other members of the health care team or communityX
      4.4EServes as advisor, mentor, preceptor, and/or committee member for graduate-level researchX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AFacilitates or participates in studies related to oncology nutrition care practiceXX
      4.5BCollaborates on interprofessional and/or interorganizational teams to perform and disseminate nutrition research related to oncology careXX
      4.5CParticipates in the Academy’s Evidence Analysis Library process for development or updating of oncology evidence-based practice guidelines or other topicsXX
      4.5DLeads interprofessional and/or interorganizational research activitiesX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, and customer values are integrated in the delivery of nutrition and dietetics services
      • Customers receive appropriate services based on the effective application of best available research/evidence and information
      • Best available research/evidence and information is used as the foundation of evidence-based practice
      Standard 5: Communication and Application of Knowledge

      The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.1BApplies the best available research/evidence and information in conjunction with other health care professionals to individualize patient/client careXXX
      5.1CPresents evidence-based oncology nutrition information at the local level (eg, community groups, colleagues, health care administrators, and executives)XXX
      5.1DInterprets current oncology nutrition research and applies to professional practice and to practical application in communications for diverse audiences, as appropriateXX
      5.1EMonitors food-safety regulations and evidence-based guidelines to guide oncology patient/client care and education, discussions with interprofessional team in designing program guidelines, and information communicated to the publicXX
      5.1FDemonstrates flexibility, critical thinking, and innovation with the ability to effectively apply and communicate complex ideasX
      5.1GServes as an expert reference for colleagues, other health care providers, the community, and outside agencies, related to oncology nutritionX
      5.2Selects appropriate information and the most effective communication method or format that considers customer-centered care and the needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2A1Compares and modifies communication methods to provide education and counseling to target audience to enhance comprehension of contentXX
      5.2A2Investigates target audience needs, learning style(s), and desired outcomes, and planned actions for audience to identify effective communication method(s) to achieve goalX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Participates in, uses, and/or leads electronic professional networking groups to stay current in oncology nutrition practice (eg, Academy’s Oncology Nutrition Dietetic Practice Group listserv)XXX
      5.2B2Identifies and/or develops web-based/electronic oncology nutrition education tools for target audience(s)XX
      5.2B3Contributes nutrition expertise to oncology-related bioinformatics/medical informatics projects as neededX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AIntegrates new knowledge of oncology nutrition therapy as it applies to the patient/client populationXXX
      5.3BIntegrates knowledge of oncology nutrition therapy in new and varied settings, circumstances, and use in social mediaXX
      5.3CApplies new knowledge of oncology nutrition therapy in varied context with clients/families, colleagues, and the publicX
      5.3DLeads the integration and application of new scientific knowledge into practice for complex problems, new research methodologies, and in communications with health care professionals and the publicX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Participates as an educator, mentor, or preceptor to students, interns, or health care professionals within or outside of professionXX
      5.4A2Mentors RDNs interested in pursuing CSO or other credentialsXX
      5.4A3Develops educational and/or mentorship programs for health care professionals that promote nutrition in oncology care and educationX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Identifies, directs, and guides consumers to appropriate oncology nutrition information (eg, American Institute for Cancer Research; American Cancer Society; Academy Oncology Nutrition Dietetic Practice Group)XXX
      5.4B2Facilitates collaborations with community groups to disseminate oncology nutrition informationXX
      5.4B3Directs and manages systematic processes to identify, track, and monitor utilization of client resourcesX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Sharpens written and oral communication skills with the ability to translate complex scientific and policy information to the publicXXX
      5.4DReflects knowledge of population characteristics in communication methodsXXX
      5.4D1Reflects knowledge of population characteristics in communication methods used with patient/client population (eg, literacy and numeracy levels, need for translation of written materials or a translator, communication skills)XXX
      5.4EInterprets information and research related to conventional and complementary oncology nutrition for patients/clients, colleagues, and the publicXX
      5.4FDevelops oncology nutrition articles and other resources for consumers and other health care professionalsXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5AContributes formally and informally to the patient care team (eg, shares relevant articles, investigates queries)XXX
      5.5BPromotes the specialized knowledge and skills of the oncology RDN with the CSO or other credentials to the interprofessional teamXX
      5.5CParticipates in interprofessional collaborations at the organization or systems level (eg, state or community advisory boards, nonprofit organizations/agencies)XX
      5.5DIdentified as an expert/resource of scientific information in oncology nutrition and/or related field by colleagues and/or medical communityX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents information on evidence-based oncology research and information at the local level (eg, community groups, colleagues)XXX
      5.6BInitiates and/or serves on planning committees/task forces to develop continuing education or community programsXXX
      5.6CPresents at local, regional, and national meetings and authors oncology-related publicationsXX
      5.6DServes in a leadership role for oncology-related publications and program planning of regional and national meetingsXX
      5.6EServes as an author of oncology-related publications and oncology presenter for consumer and health care provider audiences on oncology topicsXX
      5.6FServes as consultant to business, industry, and national oncology organizations regarding education needs of survivors, consumers, and health care providersXX
      5.6GUses experience and data (eg, position papers, practice papers, meta-analysis, review articles) to generate new knowledge and develop new guidelines, programs, and policies in oncology practice areasX
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations, or non-profit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AUses habits of good interfacing (communication, information gathering and practices) to lead in oncology nutritionXXX
      5.7BServes on local oncology planning committees/task forces for health professionals, industry, and communityXXX
      5.7CServes on regional and national oncology planning committees/ taskforces/advisory boards for health-related organizations, industry, and the community (eg, ACoS Commission on Cancer)XX
      5.7DParticipates as invited reviewer, author, or presenter at local and regional meetings and media outletsXX
      5.7EParticipates in leadership role for publications (ie, editor, editorial advisory board) and on program planning committeesXX
      5.7FProactively seeks opportunities (local, regional, and national, and international levels) to integrate practice expertise and programs with larger system (ie, American Cancer Society), and oncology-specific professional groups (eg, American Society for Clinical Oncology, Oncology Nursing Society, ACoS Commission on Cancer, NCCN)X
      5.7GParticipates as invited reviewer, author, or presenter at national, international meetings and media outletsX
      5.7HServes as national and international oncology nutrition media spokespersonX
      5.7IServes in leadership positions and is identified as an evidence-based oncology nutrition opinion leaderX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated and shared
      • Interoperable information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
      • Individuals, groups, and stakeholders:
        • Receive current and appropriate information and customer-centered service
        • Demonstrate understanding of information and behavioral strategies received
        • Know how to obtain additional guidance from the RDN or other RDN-recommended resources
      • Leadership is demonstrated through active professional and community involvement
      Standard 6: Utilization and Management of Resources

      The registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, natural and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1AParticipates in operational planning of oncology nutrition programs (ie, staffing, marketing, budgeting, billing, program planning)XXX
      6.1BCollaborates with administrative, medical, and foodservice staffs in operational planning and to secure resources and services to achieve desired oncology nutrition outcomesXX
      6.1CManages and coordinates effective delivery of oncology nutrition programs and services; understands revenue stream and insurance reimbursement trendsXX
      6.1DLeads strategic and operational planning, implementation, and monitoring for maintaining and managing resources for oncology programs and servicesX
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2BCollects or contributes data to document costs of delivering programs and servicesXXX
      6.2CParticipates in analyzing patient/client population and outcomes data, program resource/service participation, and expense data to evaluate and adjust programs and servicesXXX
      6.2DMonitors, documents, and evaluates program and service resource usage against budget or other metrics (eg, staff hours, staff to patient/client ratio, referral requests, program participation rates, revenue/insurance reimbursement data, and supplies, training, technology, professional development, and food cost, as applicable)XX
      6.2EDirects operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications to design and delivery of oncology nutrition programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AUnderstands and complies with The Joint Commission standards (www.jointcommission.org), the ACoS Commission on Cancer’s Cancer Program Standards: Ensuring Patient-Centered Care (www.facs.org/cancer/coc/programstandards.html), and those of other accreditation bodiesXXX
      6.3BParticipates in the evaluation and selection of new products and equipment to assure safe, optimal, and cost-effective delivery of oncology nutrition care and services at the systems levelXX
      6.3CMonitors infection control reports and compliance with food safety guidelines to contribute to reports and identify opportunities for improvementXX
      6.3DAnalyzes safety and effectiveness in meeting needs of target population and program/service goals; and cost in planning, budgeting, and delivering services and products at the organization and systems levelX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4ACollects QAPI data using designated tools and analyzes to improve outcomes and identify best practices in collaboration with others as neededXXX
      6.4BDevelops or adapts QAPI tools for organizational needsXX
      6.4CUsing data, proactively recognizes needs, anticipates outcomes and consequences of different approaches, and makes necessary modifications to plans to achieve desired patient-/client-related and departmental/program resource allocation outcomesXX
      6.4DIntegrates quality measures and performance improvement processes into management of human and financial resources and information technologyX
      6.4EShares QAPI results via professional presentations and publishing at the local, regional, and national levelX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5ADevelops or modifies programs and services to improve stakeholder (eg, patient/client, caregivers, employees, administration) satisfaction with oncology nutrition programs and servicesXX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed
      • Documentation of resource use is consistent with operational and sustainability goals
      • Data are used to promote, improve, and validate services, organization practices, and public policy
      • Desired outcomes are achieved, documented, and disseminated
      • Identifies and tracks key performance indicators in alignment with organizational mission, vision, principles, and values
      a Oncology: Oncology is a branch or of medicine addressing the prevention, diagnosis, and treatment of cancer. The cancer care continuum encompasses prevention, treatment, recovery from treatment, survivorship, living with cancer, palliative/hospice care. An oncology RDN may practice in, but is not limited to, the following settings and disciplines: medical oncology, surgical oncology, radiation oncology, cancer prevention/wellness, hematology, hematopoietic stem cell transplant, palliative care/hospice, and oncology nutrition-related research. An oncology RDN’s practice reflects the setting and populations served (eg, pediatrics or adults) with diverse cancer diagnoses, including expanded roles and responsibilities reflecting the RDN’s interests and the organization’s activities (eg, research, case management, management of patients/clients receiving home nutrition support [enteral and/or parenteral nutrition]).
      b Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary
      c PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
      d Medical staff: Medical staff is composed of doctors of medicine or osteopathy and can, in accordance with state law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed January 10, 2018.

      e Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed January 10, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed January 10, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final rule (FR DOC# F2016; pp 68688-68872)−Federal Register October 4, 2016; 81 (192): 68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed January 10, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual−Appendix PP-Guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 Physician Services, §483.60 Food and Nutrition Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed January 10, 2018.

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      Biography

      P. Charuhas Macris is a nutrition education coordinator, Seattle Cancer Care Alliance, Seattle, WA.
      K. Schilling is an outpatient oncology dietitian, Maine Medical Center, Portland.
      R. Palko is a clinical dietitian, Stanford Health Care, Stanford, CA.