Advertisement

Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition

      Abstract

      Nephrology nutrition encompasses therapeutic and preventive nutrition care for individuals through the life cycle and addresses a variety of kidney disorders. Most nephrology nutrition practice focuses on care of individuals with chronic kidney disease, those on dialysis, and recipients of kidney transplants. The Renal Dietitians Dietetic Practice Group, National Kidney Foundation Council on Renal Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nephrology nutrition. The SOP and SOPP for RDNs in Nephrology Nutrition provide indicators that describe three levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the following six domains that focus on 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. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nephrology nutrition and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonline.org.
      The Academy of Nutrition and Dietetics (Academy) Renal Dietitians Dietetic Practice Group (RPG), and the National Kidney Foundation Council on Renal Nutrition (NKF-CRN), under the guidance of the Academy Quality Management Committee, have revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Nephrology Nutrition previously revised in 2014.
      • Kent P.S.
      • McCarthy M.P.
      • Burrowes J.D.
      • et al.
      Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition.
      ,
      • Kent P.S.
      • McCarthy M.P.
      • Burrowes J.D.
      • et al.
      Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition.
      The revised document, Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition, reflects advances in nephrology nutrition practice during the past 6 years and replaces the 2014 Standards. This document builds 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 for the Nutrition and Dietetics Profession,
      Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR)
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics.
      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, or employers 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.eatrightpro.org/advocacy/licensure/licensure-map.
      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 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 Renal Nutrition [CSR], Geriatrics [CSG], or Pediatrics [CSP]; Advanced Practitioner Certification in Clinical Nutrition [RDN-AP]; Certified Diabetes Care and Education Specialist [CDCES]; Certified Clinical Transplant Dietitian [CCDT] or Certified Case Manager [CCM]). The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skills, experience, judgment, and demonstrated competence using criteria resources.
      Scope of Practice Decision Algorithm.
      This article is being published concurrently in the Journal of Renal Nutrition. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article.
      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.
      Approved September 2020 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Renal Dietitians Dietetic Practice Group of the Academy and the National Kidney Foundation Council on Renal Nutrition. Scheduled review date: February 2027. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Nephrology Nutrition may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J. Gilmore, MS, RDN, LD, FADA, FAND, scope/standards of practice specialist, Quality Management at [email protected].
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital
      State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      and Critical Access Hospital
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
      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/dietorders/). 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 through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.
      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 27106-27157).
      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, now “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.
      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#2016; 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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      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 (https://www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). 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 (new revisions are italicized and in red color).
      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.
      The CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at https://www.cms.gov/files/document/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, equitable, 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 nephrology 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 nephrology 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, measurable action statements that illustrate how each standard can be applied in practice) (Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in Nephrology Nutrition were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Nephrology Nutrition were reviewed and approved by the Executive Committee of the Renal Dietitians Dietetic Practice Group, the Executive Committee of the National Kidney Foundation’s Council on Renal Nutrition, 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. On successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages their 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 Nephrology Nutrition. In Academy focus areas, the three levels of practice are represented as competent, proficient, and expert.
      With safety and evidence-based practice as guiding factors when working with patients/clients/customers/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.
      The Academy offers a webinar, Evidence-Based Nutrition Using Scientific Evidence to Inform Clinical Practice (www.eatrightstore.org/cpe-opportunities/recorded-webinars) that presents the five-step evidence-based process as a mechanism to acquire and critique evidence for practicing evidence-based nutrition care. The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence to converse authoritatively with the interdisciplinary team and adequately involve the patient/client/customer/population in shared decision making.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nephrology 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 Nephrology 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 Nephrology 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 in which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares their 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 Algorithm 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 nephrology 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 individuals of all ages. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family, advocate 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 outcome-focused statements against which a practitioner’s performance can be assessed. 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 nephrology nutrition (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN providing nephrology nutrition.
      Standards described as proficient level of practice in this document are not equivalent to the CDR certification, Board Certified as a Specialist in Nephrology Nutrition (CSR). Rather, the CSR designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination, nephrology nutrition knowledge and application beyond the competent practitioner and demonstrates, at a minimum, proficient-level skills. An RDN with the CSR designation is an example of an RDN who has demonstrated additional knowledge, skills, and experience in nephrology nutrition by the attainment of a specialist credential.
      Figure thumbnail fx1

      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 their 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. 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. 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 career as an RDN in nephrology nutrition is an evolving process of advancement in skill as well as expanding and changing areas of interest and engagement. A competent RDN in nephrology nutrition is learning the principles of nephrology nutrition and becoming familiar with evidence-based practice guidelines in nephrology, including those published by the Academy Evidence Analysis Library (EAL), Kidney Disease Outcomes Quality Initiative (KDOQI),
      Kidney Disease Outcomes Quality Initiative (KDOQI) History.
      ,
      National Kidney Foundation KDOQI Clinical Practice Guidelines in Children with CKD 2008 Update.
      and Kidney Disease Improving Global Outcomes (KDIGO)
      Kidney Disease Improving Global Outcomes (KDIGO) Guidelines. KDIGO.
      (See Figure 4). The competent-level practitioner in nephrology nutrition is developing an understanding of approaches to nutrition assessment, diagnosis, and care planning in nephrology and is learning about common co-morbidities and appropriate management.
      • Beto J.A.
      • Ramirez W.E.
      • Bansal V.K.
      Medical nutrition therapy in adults with chronic kidney disease: Integrating evidence and consensus into practice for the generalist registered dietitian nutritionist.
      An RDN aspiring to enter the focus area of nephrology nutrition in a dialysis setting must have a minimum of 1 year of clinical experience, as required by the CMS Conditions for Coverage.
      42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for coverage for end-stage renal disease facilities; Final Rule.
      The Academy’s Certificate of Training program in Chronic Kidney Disease Nutrition Management may be a valuable resource for knowledge and skill acquisition for the competent-level RDN (https://www.eatrightstore.org/collections/chronic-kidney-disease-nutrition-management). It is also important for RDNs new to nephrology nutrition to become familiar with the regulatory and quality standards of this focus area.
      Figure 4Resources for Registered Dietitian Nutritionists in Nephrology Nutrition (not all inclusive).
      ResourceAddressDescription
      Academy of Nutrition and Dietetics (Academy) Resources
      Academy Renal Practice Group (RPG)www.renalnutrition.orgThis Academy dietetic practice group strives to empower its members to be the nation’s leaders in nephrology nutrition. RPG offers resources for registered dietitian nutritionists (RDNs) in nephrology nutrition, such as access to a newsletter, electronic mailing list, member resource library including patient education materials, continuing professional education opportunities, and webinars.
      Certificate of Training Program: Chronic Kidney Disease Nutrition Managementhttps://www.eatrightstore.org/collections/chronic-kidney-disease-nutrition-managementThis online certificate of training program assists RDNs to further their skills and advance their practice related to chronic kidney disease (CKD) management. The program consists of five separate modules that include topics such as CKD basics, preventing and slowing progression of CKD, increased complications as kidney function declines, diet for CKD, and transition of CKD to kidney failure.
      Chronic Kidney Disease and the Nutrition Care Processhttps://www.eatrightstore.org/product-type/ebooks/chronic-kidney-disease-and-the-nutrition-care-process-ebookThis book provides the latest evidence-based guidelines and recommendations regarding medical nutrition therapy for CKD. Each chapter includes a case study that illustrates progression through the nutrition care process.
      A Clinical Guide to Nutrition Care in Kidney Disease, 2nd Edhttps://www.eatrightstore.org/product-type/books/a-clinical-guide-to-nutrition-care-in-kidney-disease-2edThis book discusses kidney disease in adults and children, from early-stage CKD to dialysis, transplantation, and nutrition support therapies. It includes information on nocturnal home dialysis, dietary supplements, and acute kidney injury and is a good resource for RDNs preparing for the Board Certified Specialist in Renal Nutrition (CSR) credentialing exam. The 3rd edition is forthcoming in 2021.
      Making Choices: Meal Planning for Diabetes and CKDhttps://www.eatrightstore.org/product-type/ebooks/making-choices--meal-planning-for-people-with-diabetes-and-chronic-kidney-disease-stages-3-and-4-eboThis book assists RDNs in counseling patients/clients with both diabetes and CKD. It includes: A Practitioner’s Guide, Making Choices: Meal Planning for People with Diabetes and CKD Disease Stages 3 and 4, and other supplementary patient education handouts.
      National Kidney Diet: Dish Up a Kidney/Dialysis-Friendly Meal (Joint Resources between RPG and the National Kidney Foundation Council on Renal Nutrition [NKF-CRN])https://www.eatrightstore.org/product-type/brochures-handouts/dish-up-a-dialysis-friendly-meal

      https://www.eatrightstore.org/product-type/brochures-handouts/dish-up-a-kidney-friendly-meal
      The updated National Kidney Diet includes handouts for educating patients/clients on meal planning for kidney disease. There are versions for CKD and dialysis, and the handouts include sample healthy meal plans, advice for planning meals, and guidelines and tips for making choices from each food group.
      Nutrition Focused Physical Exam Pocket Guide, 2nd Ed.https://www.eatrightstore.org/product-type/ebooks/nutrition-focused-physical-exam-pocket-guide-second-edition-ebookThis pocket guide provides RDNs with tools for malnutrition assessment, documentation, and coding, and also includes resources such as an adult malnutrition characteristics chart, and a physical exam table describing muscle and fat wasting, micronutrient deficiencies and toxicities, and edema charts.
      Academy Find an Expert servicehttps://www.eatright.org/find-an-expertThe Academy of Nutrition and Dietetics’ Find a Registered Dietitian Nutritionist online referral service allows you to search a national database of Academy members for the exclusive purpose of finding a qualified RDN. Users can search by area of expertise to find specialists in kidney and renal diseases.
      Commission on Dietetic Registration (CDR) Preceptor Training Coursehttps://www.cdrnet.org/news/online-dietetics-preceptor-training-course-free-of-chargeCDR provides a free, self-paced training course to prepare RDNs to serve as preceptors for interns, students, and peers. The training course is approved for 8 CPEUs for RDNs.
      National Kidney Foundation (NKF) Resources
      NKF Council on Renal Nutrition (CRN)https://www.kidney.org/professionals/CRNThe Council on Renal Nutrition (CRN) functions as a professional council within the framework of the National Kidney Foundation (NKF) and networks with other organizations to support the National Kidney Foundation's goal of making lives better for those with CKD through education, outreach, and research in the field of nutrition as it pertains to prevention, eradication, and treatment of kidney and urologic diseases.
      Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelineshttps://www.kidney.org/professionals/guidelinesKDOQI has published 13 evidence-based guidelines to guide clinical practice in the care and management of individuals with CKD and end-stage kidney disease (ESKD). KDOQI also provides collaboration through wider policy and education programs to support implementation of guideline recommendations.
      NKF Professional Education Resource Center (PERC)https://education.kidney.org/This resource center is designed for professionals committed to continuing their education and improving patient outcomes. PERC provides resources such as free courses in topics such as managing iron-deficiency anemia in non-dialysis CKD, activity programs, frequently asked questions, and events.
      CRN Pocket Guide to Nutrition Assessment in the Patient with CKDhttps://nkf.worksmartsuite.com/UserEditFormFilling.aspxThis pocket guide resource provides specific chapters based on KDIGO (see below) and KDOQI guidelines and recommendations for nutrition; peritoneal dialysis and hemodialysis; diabetes; cardiovascular disease, dyslipidemia, hypertension; CKD mineral and bone disorder; and CKD-related anemia. Special populations include acute kidney injury, gout, HIV/AIDS, nephrolithiasis, nephrotic syndrome, older adults, pediatrics, pregnancy, and kidney transplant. The 5th edition is currently available to CRN members in a PDF format, and the 6th edition is in process. The pocket guide is an excellent resource for preparing for the CSR exam.
      CKD Dietitian Directoryhttps://sites.google.com/view/ckdrd/homeThis directory is provided by the National Kidney Foundation Council on Renal Nutrition as a resource to individuals looking for RDNs that treat pre-dialysis chronic kidney disease patients.
      Other Resources
      National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)https://www.niddk.nih.gov/The NIDDK, part of the National Institutes of Health, conducts and supports medical research training and disseminates evidence-based information on diabetes and other endocrine and metabolic diseases, digestive diseases, nutritional disorders, and obesity; and kidney, urologic, and hematologic diseases, to improve health and quality of life. The NIDDK provides a variety of resources of value to patients, health professionals, and educators and is now home to the resources of the National Kidney Disease Education Program (NKDEP).
      Kidney Disease Improving Global Outcomes (KDIGO)https://kdigo.org/KDIGO is a global nonprofit organization developing and implementing evidence-based clinical practice guidelines in kidney disease. KDIGO’s 12 guidelines translate global scientific evidence into practical recommendations for clinicians and patients, guiding prevention or management of individuals with kidney diseases.
      American Kidney Fundhttps://www.kidneyfund.org/The American Kidney Fund’s mission is to fight kidney disease and help people live healthier lives with programs that support people wherever they are in their fight against kidney disease. They provide resources for kidney patients and nephrology professionals, including free, accredited online continuing education courses.
      Kidney Schoolhttps://kidneyschool.org/Provides information about kidney disease and dialysis helpful for RDNs new to nephrology as well as continuing education and patient education materials.

      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. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice. The proficient-level practitioner in nephrology nutrition has gained additional work experience in the care of patients/clients with kidney disease and has developed a deeper understanding of nephrology nutrition concepts and principles. The proficient-level RDN in nephrology may begin to develop deeper, focused knowledge of specific renal replacement therapies such as home dialysis or kidney transplant, in populations such as pediatrics, or in one or more aspects of nephrology nutrition practice, such as management of chronic kidney disease (CKD), fluids or anemia, mineral and bone disorder, malnutrition/malnutrition-inflammation syndrome, or use of plant-based diets. The RDN may be working toward or have obtained the education, knowledge, and experience to be eligible for the Board Certification as a Specialist in Renal Nutrition (CSR) 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 on nutrition and dietetics. An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s) such as the CDR Advanced Practitioner Certification in Clinical Nutrition, CDR Certified Specialist in Renal Nutrition or Pediatrics, or the Certified Clinical Transplant Dietitian (CCTD) designation through the North American Transplant Coordinators Organization.
      Certified Clinical Transplant Dietitian (CCTD)
      NATCO.
      Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility. The expert-level practitioner in nephrology nutrition has extensive practice experience and knowledge across the spectrum of kidney disease stages and renal replacement therapies and demonstrates an intuitive understanding of nephrology nutrition concepts. The expert RDN formulates clinical judgments through a combination of education, experience, intuition, and critical thinking. As an expert in nephrology nutrition, the RDN may function in an expanded or leadership role within the facility or organization. The Expert RDN in nephrology nutrition leads efforts to advance nephrology nutrition practice and advocates for policies and practice that are supported by current evidence.
      These Standards, along with the Academy/CDR Code of Ethics,
      Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR)
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics.
      answer the questions: Why is an RDN uniquely qualified to provide nephrology nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, equitable, and quality nephrology nutrition care and service at the competent, proficient, and expert levels?

      Overview

      Nephrology nutrition encompasses therapeutic and preventive nutrition care for individuals through the life cycle and addresses a variety of kidney disorders. Most nephrology nutrition practice focuses on care of individuals with CKD, those on dialysis, and recipients of kidney transplants. RDNs in nephrology nutrition also may provide therapeutic nutrition for management of nephrolithiasis or rare kidney disorders.
      Chronic kidney disease is most commonly a complication of diabetes or hypertension. It also may be caused by or associated with multiple chronic conditions, including cardiovascular disease, liver disease, or obesity. Glomerulonephritis, inherited conditions such as polycystic kidney disease, autoimmune disorders such as systemic lupus erythematosus, and congenital anomalies also contribute to the burden of CKD. Acute kidney injury (AKI) can result from trauma, infection, toxicity, or shock and can lead to long-term kidney failure.
      • Meyer D.
      • Mohan A.
      • Subev E.
      • Sarav M.
      • Sturgill D.
      Acute kidney injury incidence in hospitalized patients and implications for nutrition support.
      Chronic kidney disease has been classified into five stages, as seen in Figure 5.
      Estimated glomerular filtration rate (eGFR).
      When CKD has progressed to the point that dialysis is required, the designation of Stage 5D is used. The spectrum of CKD also includes individuals who have received kidney transplants. Common diagnostic tests or indices for CKD in adults include estimated glomerular filtration rate (eGFR), albuminuria, and the albumin to creatinine ratio (ACR). Kidney biopsy is commonly used to determine the cause of CKD. Pediatric patients are assessed using the Schwartz equation.
      The Medicare End-Stage Renal Disease (ESRD) program was created in 1972, extending Medicare benefits to all with ESRD, now referred to as End-Stage Kidney Disease (ESKD) regardless of age. Medicare remains the primary payer of ESKD care in the United States. The Conditions for Coverage,
      42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for coverage for end-stage renal disease facilities; Final Rule.
      ,
      State Operations Manual. Appendix H—Guidance to surveyors: End-stage renal disease facilities (Rev. 200, 02-21-20).
      last updated in 2008, establish and regulate the standards of care for dialysis organizations. Similar regulations govern transplant centers.
      Centers for Medicare and Medicaid Services. 42 CFR Parts 405, 482, 488, and 498 Medicare Program; Hospital conditions of participation: Requirements for approval and re-approval of transplant centers to perform organ transplants; Final rule.
      ,
      State Operations Manual. Appendix X—Guidance to Surveyors: Organ Transplant Programs. (Rev 200, 02-21-20).
      It is the responsibility of every RDN to be familiar with and use the most current regulatory guidelines applicable to practice setting as they are updated over time.
      Chronic kidney disease is one of two conditions for which Medical Nutrition Therapy (MNT) is a covered Medicare benefit. Individuals with eGFR of 13 to 50 mL/min/1.73m2 (approximately CKD Stage 3b-5) or within 3 years post-transplantation are eligible. Although retrospective studies have shown that MNT can slow progression of CKD and improve biochemical markers, the therapy continues to be underutilized.
      • Kramer H.
      • Jimenez E.Y.
      • Brommage D.
      • et al.
      Medical nutrition therapy for patients with non-dialysis-dependent chronic kidney disease: Barriers and solutions.
      In one 2011 study, only 12% of incident hemodialysis patients received nutrition care provided by an RDN before starting dialysis.
      • Slinin Y.
      • Guo H.
      • Gilbertson D.T.
      • et al.
      Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.
      The most recent US Renal Data System (USRDS) data indicate that 11.4% of incident ESKD patients in the Medicare population received care from a dietitian before starting dialysis.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2018 Annual data report: Kidney.
      From 2016 to 2017, the last year for which data is available at time of print, the prevalence of CKD in Medicare patients older than 65 years of age increased from 13.8% to 14.5%; most were classified as Stage 3. Incidence of CKD is higher in males, older adults, blacks, and non-Hispanic whites.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2018 Annual data report: Kidney.

      Jimenez EY, Kelley K, Brommage D, et al. Patient perspectives on access to medical nutrition therapy for nondialysis dependent chronic kidney disease. Poster presented at: National Kidney Foundation Spring Clinical Meetings 2020; March 2020.

      Although the incidence of ESKD in the United States has been relatively flat since 2006, the prevalence continues to increase, as the population ages and survival on dialysis improves.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2018 Annual data report: Kidney.
      Total Medicare spending for CKD and ESKD in the Medicare population exceeded $120 billion in 2017, accounting for 33.8% of total Medicare spending.
      The primary renal replacement therapy in the United States remains in-center hemodialysis; approximately 83% of ESKD patients initiate treatment with this therapy. Use of home dialysis therapies, including peritoneal dialysis (PD) and home hemodialysis (HHD) have increased significantly since 2007, but utilization remains low, with only 4% of patients starting on HHD and 10% on PD. Approximately 30% of people on dialysis ultimately receive kidney transplants, but only 1% of adults receive them preemptively.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2018 Annual data report: Kidney.
      Adults with CKD may also be cared for with conservative management strategies instead of dialysis or transplantation. In the pediatric population, 28% of patients initiate therapy with PD, and 21% receive preemptive transplants before requiring dialysis.
      • Hart A.
      • Smith J.M.
      • Skeans M.A.
      • et al.
      OPTN/SRTR 2018 Annual data report: Kidney.
      Individuals with AKI may be treated in acute care settings with hemodialysis (HD) or continuous renal replacement therapy (CRRT). An increasing number of AKI patients receive hemodialysis in an outpatient setting once medically stable after changes in Medicare payment policies.
      The KDOQI,
      Kidney Disease Outcomes Quality Initiative (KDOQI) History.
      established in 1995 by the NKF, has published 13 sets of clinical practice guidelines governing aspects of CKD care. The first practice guidelines for nephrology nutrition were published by KDOQI in 2000 and were subsequently evaluated through the EAL’s systematic review process, resulting in practice guidelines for CKD. Beginning in 2015, the Academy and NKF partnered to update the 2000 KDOQI nutrition guidelines. The updated KDOQI nutrition guidelines were published in 2020.
      • Ikizler T.A.
      • Burrowes J.D.
      • Byham-Gray L.D.
      • et al.
      KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update.
      , The KDIGO initiative has also published international evidence-based practice guidelines for care of people with CKD.
      Kidney Disease Improving Global Outcomes (KDIGO) Guidelines. KDIGO.
      The KDOQI and KDIGO guidelines are used by nephrology practitioners to manage aspects of care, such as bone disease, anemia, diabetes, and dialysis adequacy, and for the care of specific populations such as pediatric patients
      National Kidney Foundation KDOQI Clinical Practice Guidelines in Children with CKD 2008 Update.
      and transplant recipients.
      People with CKD experience a number and variety of comorbidities, particularly in the more advanced stages. They are at risk for protein-energy or protein malnutrition, resulting from increased protein and energy needs, anorexia, and protein losses via dialysis. Malnutrition may contribute to growth and developmental delays in children with CKD.
      • Silverstein D.M.
      Growth and nutrition in pediatric chronic kidney disease.
      Abnormal vitamin D activation and imbalances of calcium and phosphorus cause bone disease, most commonly of a high-turnover variety. Extraskeletal calcification may occur, impacting the heart, lungs, and vasculature.
      • Meyer D.
      • Mohan A.
      • Subev E.
      • Sarav M.
      • Sturgill D.
      Acute kidney injury incidence in hospitalized patients and implications for nutrition support.
      Calcifications in dermal tissues can progress to calciphylaxis, which is fatal in over 50% of cases.
      • Bhambri A.
      • Del Rosso J.Q.
      Calciphylaxis: A review.
      Erythropoiesis is impaired with declining kidney function, resulting in anemia that typically requires medical intervention. Micronutrient deficiencies may occur, particularly in individuals on dialysis, who are susceptible to deficiencies of water-soluble vitamins such as B vitamins and vitamin C.
      • Meyer D.
      • Mohan A.
      • Subev E.
      • Sarav M.
      • Sturgill D.
      Acute kidney injury incidence in hospitalized patients and implications for nutrition support.
      More than 90% of dialysis patients are deficient in vitamin D.
      • Blair D.
      • Byham-Gray L.
      • Lewis E.
      • McCaffrey S.
      Prevalence of vitamin D [25(OH)D] deficiency and effects of supplementation with ergocalciferol (vitamin D2) in stage 5 chronic kidney disease patients.
      Deficiencies of zinc and iron may also occur. Failure to thrive may occur in children and adults with CKD.
      • Meyer D.
      • Mohan A.
      • Subev E.
      • Sarav M.
      • Sturgill D.
      Acute kidney injury incidence in hospitalized patients and implications for nutrition support.
      Hyperlipidemia, hyperglycemia, and weight gain are common complications in patients on PD or post-transplantation. Patients with transplants are also at risk for abnormalities in serum minerals, such as magnesium and phosphorus, and malignancies related to immunosuppressive agents.
      • Danovitch G.M.
      Handbook of Kidney Transplantation.
      RDNs provide care for people with CKD in numerous and varied settings. They:
      • Practice in the dialysis industry, where RDNs are mandated members of the interdisciplinary team (IDT). This may include traditional in-center hemodialysis as well as nocturnal, self-care, and home dialysis therapy programs. RDNs must have 1 year of clinical work experience as an RDN to work in adult dialysis programs.
        42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for coverage for end-stage renal disease facilities; Final Rule.
      • Provide care to patients with CKD, ESKD, and AKI in the acute care and long-term care settings.
      • Serve on transplant teams, in which RDNs are mandated members of the IDT. Nutrition care includes evaluation of transplant candidacy, providing care before and after surgery, and long-term follow-up.
      • Provide MNT to people with CKD in CKD clinics, physician offices, private practices, and via telehealth.
      Nephrology nutrition practice includes nutrition screening, assessment, diagnosis, intervention, and evaluation, including interdisciplinary care planning, and education/counseling. RDNs play active roles in management of bone disease, malnutrition, electrolytes, fluid balance, anemia, nephrolithiasis, body weight (especially pre-transplantation), and diabetes. In many nephrology practice settings, the RDN is often the sole nutrition resource to the team, providing education to staff and support to nephrologists. RDNs may be actively involved in quality improvement and oversight of dialysis adequacy. RDNs ensure continuity of care between settings and support medication management and adherence.
      In addition to practicing MNT, RDNs in nephrology may serve in expanded roles such as case/care managers, treatment options or kidney disease educators, quality improvement specialists, pharmaceutical clinical specialists/liaisons, managers, or executives. RDNs also may have operations, finance, research, education, or business development responsibilities.
      The Academy’s Renal Practice Group (RPG) provides resources, advocacy, and networking for practitioners in nephrology nutrition. The Renal Nutrition Forum is published 3 times per year, providing continuing education articles and patient-oriented resources. RPG’s website (www.renalnutrition.org) houses a growing library of patient education materials and a collection of on-demand webinars. RDNs in nephrology nutrition are also commonly members of the National Kidney Foundation’s Council on Renal Nutrition (CRN) at both national and regional or local levels. The CRN supports professional education, patient and public education, public policy, and research in nephrology. Members receive the Journal of Renal Nutrition and the RenaLink newsletter. The Council website (https://www.kidney.org/professionals/CRN) hosts a variety of resources.

      Academy Revised 2020 SOP and SOPP For RDNs (Competent, Proficient, and Expert) in Nephrology Nutrition

      An RDN can use the Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Nephrology Nutrition (Figs 1 and 2, available at www.jandonline.org, and Fig 3) to:
      • identify the competencies needed to provide nephrology nutrition and dietetics care and services;
      • self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, and quality nephrology 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 nephrology nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in nephrology nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of nephrology nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of nephrology nutrition and dietetics care and services;
      • guide the development of nephrology nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, 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 nephrology 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 nephrology nutrition is learning the principles that underpin this focus area and is developing knowledge, skills, judgment and gaining experience for safe and effective nephrology 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 nephrology nutrition must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and available resources to support and ensure quality nephrology nutrition-related nutrition and dietetics practice. The competent-level RDN will likely begin practice in nephrology nutrition by caring for a subset of patients/clients within the spectrum of kidney disease, such as in a dialysis center or a kidney transplant program. The competent-level nephrology RDN functions as a member of the interdisciplinary team in the practice setting and may educate team members of other disciplines on the nutritional aspects of nephrology care.
      At the proficient level, an RDN has developed a more in-depth understanding of nephrology nutrition practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations (eg, addressing comorbidities impacting CKD or ESKD care; renal replacement therapies; and tailoring to population or age group, ethnic or cultural group, or socioeconomic limitations). The RDN at the proficient level is gaining the experience, knowledge, and skills needed to successfully obtain the CSR from the Commission on Dietetic Registration. The CSR credential recognizes specialized knowledge and practice and signifies proficiency in the provision of nephrology nutrition services in numerous practice settings or populations (eg, hemodialysis, peritoneal dialysis, transplantation, CKD) in adults and adolescents. The CSR credential may differentiate the nephrology nutrition practitioner to employers or among peers.
      A proficient-level RDN in nephrology nutrition may be developing expertise in specific aspects of nutritional management and care of patients/clients with kidney disease, such as mineral and bone disorder, anemia, malnutrition, dialysis adequacy, or specific renal replacement therapies. The proficient RDN may lead quality improvement, patient education, or research activities within the facility or may participate in similar activities at a department or organization level.
      At the expert level, the RDN thinks critically about nephrology nutrition and dietetics, demonstrates a more intuitive understanding of the practice area, 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 nephrology nutrition RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of nephrology nutrition and dietetics within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement nephrology 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 or lead IDTs; and lead the advancement of nephrology nutrition and dietetics practice.
      Expert-level RDNs in nephrology nutrition develop, lead, and manage projects or initiatives that have a broad impact on the organization, the community, the population, or the profession. The expert-level RDN in nephrology nutrition may participate in the development of organization-approved protocols pertinent to nutrition, such as for adjusting kidney disease-related medications based on analysis of the nutrition assessment and biochemical parameters. In addition to providing nutrition care and services for specific CKD population(s), the expert nephrology RDN may provide recommendations for the overall care or treatment of the patient to the IDT or other providers, may teach other members of the IDT, or may participate in the development of organization policies, benchmarking, or quality management to support nephrology nutrition. The expert RDN identifies opportunities to mentor others and serves in leadership roles in facilities, organizations, workgroups, or government to advance the profession and practice of nephrology nutrition.
      Indicators for the SOP and SOPP for RDNs in Nephrology 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 Nephrology Nutrition, an ”X" in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity or seek assistance to learn how to perform at the level of the standard. A competent RDN in nephrology nutrition could be an RDN starting practice after registration with 1 year of clinical experience or an experienced RDN who has recently assumed responsibility to provide nephrology nutrition care for patients/clients (eg, patients/clients on dialysis; pre- and post-transplantation; with CKD not yet on dialysis or choosing conservative management; with AKI; or with varying stages of CKD in acute or long-term care settings).
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of nephrology nutrition and dietetics and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, providing care to patients/clients from multiple populations or on varied renal replacement therapies; caring for patients/clients with complex comorbidities; providing recommendations for patients/clients with complications of CKD treatment, such as mineral and bone disorder, malnutrition, failure to thrive).
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of nephrology 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 Figures 1 and 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 nephrology 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 Nephrology 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 Nephrology Nutrition at determined intervals to evaluate their individual focus area knowledge, skills, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal also enables nephrology nutrition RDNs to better use 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 5-year recertification cycle 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 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 nephrology nutrition as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 6 for role examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in Nephrology Nutrition.
      Figure 6Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Nephrology Nutrition.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      For each role, the RDN updates their professional development plan to include applicable essential practice competencies for nephrology nutrition care and services.
      Clinical practitioner, dialysis centerA registered dietitian nutritionist (RDN) working in a dialysis center is seeing more patients with multiple comorbidities (eg, diabetes) complicating care of their end-stage kidney disease (ESKD). The RDN uses the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Nephrology Nutrition, and consults with a more experienced nephrology nutrition RDN colleague to create a personal learning plan for developing expertise and advancing practice in the care of patients/clients with ESKD and chronic kidney disease (CKD). The development plan includes a goal of obtaining Board Certification as a Specialist in Renal Nutrition (CSR).
      Clinical practitioner, kidney transplant centerAn RDN working in a kidney transplant center is evaluating patients/clients with CKD/ESKD in preparation for transplantation and following patients and living donors post-transplantation. Because this population has multiple complex comorbidities and conditions, the RDN periodically reviews the SOP and SOPP in Nephrology Nutrition and included resources with the goal of achieving the expert-level indicators for quality and safe practice and for career advancement.
      Clinical practitioner, post-acute and long-term careAn RDN consultant to a long-term care facility notices an increase of residents receiving in-center hemodialysis as a result of ESKD. The RDN refers to the SOP and SOPP in Nephrology Nutrition to enhance knowledge and skills to guide assessment and plan of care decision making for these individuals. The RDN reviews the resources identified in the article and indicators to enhance knowledge and identify areas for continuing education. The RDN contacts an RDN colleague at the dialysis center to review nutrition care plans and diet orders for necessary modification considering resident’s menu/snack/dining preference options to support nutritional needs.
      Clinical practitioner, in-patient careAn RDN working in a community hospital sees patients/clients with acute kidney injury (AKI) requiring dialysis. The RDN recognizes the need for more background with this diagnosis and reviews available published practice guidelines and nutrition resources for individualized medical nutrition therapy application. The RDN uses the SOP and SOPP in Nephrology Nutrition to evaluate current knowledge, skills, experience, and competence for identifying areas to strengthen. The RDN consults with an expert-level RDN in nephrology nutrition to gain more insight on the needs and nutrition care for individuals with AKI and for continuing education recommendations.
      Clinical practitioner, outpatient/private practiceA private practice RDN receives physician referrals to provide nutrition consultations to patients/clients with CKD in person or via telehealth. The RDN consults the SOP and SOPP in Nephrology Nutrition to become more familiar with the knowledge, skills, and resources needed to serve this population. The RDN also uses the resources to identify expanding opportunities such as supermarket tours to provide services to CKD patients/clients. The RDN monitors all relevant state laws and regulations, the Academy telehealth resources, and CMS regulations to guide practice. The RDN identifies when an RDN with more expertise in nephrology nutrition needs to be consulted or to make a referral for assuring quality care.
      Food and nutrition services manager/directorAn RDN food and nutrition director at the community hospital maintains a contract with a home-delivered meals program that serves participants with special diet needs, including several who have CKD. The RDN ensures that meals comply with the program’s nutrition guidelines and participants’ diet orders, using the hospital’s diet manual. The RDN reviews the SOP and SOPP in Nephrology Nutrition to identify resources on CKD and needs for individuals on dialysis. The RDN consults with the RDN at the community’s dialysis center for guidance on menu options and resources for recipe development and modifications.
      ResearcherAn RDN working in a research setting is awarded a grant to document the impact of nutrition interventions provided by an RDN on the health outcomes of individuals with CKD. The RDN uses the SOP and SOPP in Nephrology Nutrition in consultation with proficient- and expert-level nephrology RDNs as a resource in designing the research protocol. The SOP and SOPP also identifies areas for staff development or collaboration with a colleague more experienced in nephrology nutrition research.
      Faculty, nutrition and dietetics education programAn RDN faculty member reviews the SOP and SOPP in Nephrology Nutrition to gain additional familiarity with the role of the nephrology RDN in practice to expand lecture content and assigned readings for students. The RDN also contacts a nephrology nutrition RDN for key principles, practice guidelines and tips, and nephrology nutrition practitioner highlights before developing lectures and assignments.
      a For each role, the RDN updates their professional development plan to include applicable essential practice competencies for nephrology nutrition care and services.
      In some instances, components of the SOP and SOPP for RDNs in Nephrology 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 nephrology nutrition RDNs in practice settings and professional activities that enhance patient/client/population care or services can be used to illustrate outstanding practice models.

      Future Directions

      The SOP and SOPP for RDNs in Nephrology 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, efficient, equitable, and quality practice in nephrology nutrition remains an expectation of each revision to serve tomorrow’s practitioners and as well as patients, clients, and customers.
      The field of nephrology is entering a critical period of transition and transformation. The Advancing American Kidney Health Initiative (AAKHI), launched in 2019 by the Department of Health and Human Services, is a call to action, mandating changes, improvements, and innovations in the way kidney disease is identified and treated in the United States., Increased focus on delaying the need for dialysis, preemptive kidney transplants, strategies to increase organ donation for transplantation, and use of home dialysis therapies is likely to create new opportunities and challenges for RDNs in nephrology nutrition.
      • Moore L.W.
      • Kalantar-Zadeh K.
      Implementing the “Advancing American Kidney Health Initiative” by leveraging nutritional and dietary management of kidney patients.
      New voluntary and mandatory payment models included in the AAKHI will drive accountability for outcomes to care providers and organizations. The role of MNT and RDNs has significant potential to expand in the context of a larger focus on value-based care for people with CKD.
      ESRD Treatment Choices (ETC) Model. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      , As the nephrology and dialysis industry evolves to achieve the goals of AAKHI, there is increased need for RDNs to demonstrate the impact of nutrition care and services on CKD outcomes.
      The Academy’s ongoing advocacy for regulatory reform governing practice in ESRD facilities may provide another opportunity or advantage to the profession. Outreach to CMS, Department of Health and Human Services via the Conditions of Participation for ESRD facilities to enable RDN independent order writing for therapeutic diets and nutrition-related services in dialysis facilities when authorized to do so by the facility and medical director or, if delegated prescribing authority by the attending physician if consistent with state law, may expand the scope of practice and impact of the RDN in dialysis. Advocacy recommendations include all patient diets including therapeutic diets; orders for both standard and disease-specific medical foods/nutrition or dietary supplements, enteral and parenteral nutrition; orders for nutrition-related laboratory tests as needed to inform nutrition decisions and orders; and orders for therapeutic diets and nutrition-related services in states that do not license RDNs if delegated ordering privileges by the attending physician and consistent with state law and facility policies.
      As policy changes, so will technology. The Kidney Innovation Accelerator (KidneyX) is a partnership between the Department of Health and Human Services and the American Society of Nephrology. The goal of KidneyX is to accelerate innovations in the prevention, diagnosis, and treatment of CKD, including drugs, devices, and therapies by reducing barriers to innovation and enhancing collaboration.
      KidneyX Innovation Accelerator.
      Newer and emerging therapies and tools may create additional challenges and opportunities for RDNs practicing in nephrology. Both AAKHI and KidneyX may expand the services that RDNs may provide and be paid for as well as enable new technology tools and platforms, including telehealth and remote monitoring.
      Infection with the novel coronavirus SARS CoV-2, which reached pandemic level in 2020, is associated with acute kidney injury in approximately 9% of total cases.
      • Chen Y.T.
      • Shao S.C.
      • Hsu C.K.
      • et al.
      Incidence of acute kidney injury in COVID-19 infection: A systematic review and meta-analysis.
      The incidence of AKI in patients hospitalized with acute respiratory symptoms related to COVID-19 is significantly higher and is associated with a poor prognosis, including increased risk for CKD or ESKD and mortality.
      • Hirsch J.S.
      • Ng J.H.
      • Ross D.W.
      • et al.
      Acute kidney injury in patients hospitalized with COVID-19.
      Evidence continues to emerge as to the impact of SARS CoV-2 on the burden of kidney disease. Expanded experience with and coverage of telehealth services
      • Kalantar-Zadeh K.
      • Moore L.W.
      Renal telenutrition for kidney health: Leveraging telehealth and telemedicine for nutritional assessment and dietary management of patients with kidney disorders.
      provided by RDNs in many nephrology settings during the COVID-19 pandemic pave the way to new opportunities for RDNs to use technology to provide MNT in expedited and personalized ways.

      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 Code of Ethics for the Nutrition and Dietetics Profession, 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 Nephrology 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 kidney disease to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, efficient, equitable, 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 nephrology 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 nephrology 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, the RPG, and the NKF-CRN, 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 credentialed 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

      Special acknowledgement and thanks to Lois J. Hill, MS, RDN, LD, LDE, FAND; Kristen Nonahal, RDN, FNKF; Sara Erickson, RD, CSR, LDN; Kyle Lamprecht, MS, RD, CSP, CSR, CD-N; Golnaz Friedman, RD, CCTD; Donna Gjesvold, RD, LD; Clare Liu, MS, RDN, CSR; Lesley McPhatter, MS, RD, CSR; Carolyn Cochran, MS, RDN, LD, CDE, FNKF; and Pamela Kent, MS, RD, CDE, LD who willingly gave their time to review these standards. They also give thanks to the Renal Practice Group’s Executive Committee and National Kidney Foundation’s Council on Renal Nutrition. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND who supported and facilitated the development of these SOP and SOPPs.

      Author Contributions

      Each author contributed to drafting and 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 Nephrology 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 Nephrology Nutrition

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify 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 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
      1.1AEvaluates health status and disease condition(s) history for application to nutrition care, including:
      • medical history, etiology of kidney disease, and access to health care
      • risk factors for kidney disease (eg, family history, diabetes, hypertension, CVD
        CVD = cardiovascular disease
        , ethnicity, urinary tract infection, urolithiasis, acute kidney injury)
      • age-related nutrition issues and comorbidities (eg, diabetes, obesity, CHF
        CHF = congestive heart failure
        , hypertension, dyslipidemia, depression, GI
        GI = gastrointestinal
        diseases, gastroparesis, oral aversion, ability to chew/swallow foods or fluids)
      • evidence of malnutrition (eg, weight change, abnormal rate of growth and weight gain, prolonged poor intake, abnormal laboratory trends, previous physical assessment findings)
      • history of tobacco use (eg, cigarettes, e-cigarettes, or smokeless tobacco); and mental health, addiction, or substance use disorder
      • consumption of non-food items or other pica behaviors
      • social determinants of health (eg, health care, community resources; availability of housing and transportation; social support)
      XXX
      1.1BReviews nutrition risk screening data (eg, risk of or with malnutrition) from referring facility/provider, if available, or incorporates into nutrition assessment data collection using evidence-based screening tool (adult and pediatric)XXX
      1.1CEvaluates KDQOL
      KDQOL = Kidney Disease Quality of Life Survey
      survey results for impact on nutrition status and goals
      XXX
      1.1DEvaluates psychosocial factors or issues, including family and significant others; social or cognitive impairment support; depression/anxiety, and disordered eatingXXX
      1.1D1Assesses history of mental health disorders (eg, depression, bipolar disorder, anxiety, attention deficit hyperactivity disorder); seeks assistance if necessaryXX
      1.1EEvaluates preventive care strategies and behaviors (eg, lifestyle prevention practices, diabetes self-management)XX
      1.1FIdentifies potential nutrition complications related to chronic or acute conditions (eg, CKD-MBD
      CKD-MBD = chronic kidney disease-mineral and bone disorder
      , calciphylaxis, anemia, dysgeusia, gastroparesis, electrolyte imbalance, acidemia)
      XX
      1.1GDistinguishes underlying potential for coexisting disease or nutrition conditions that may be contributing to present nutrition/disease stateX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index [BMI], waist circumference, arm circumference, conicity index), comparison to reference data (eg, percentile ranks/z-scores), and individual patterns and historyXXX
      1.2AIdentifies appropriate adult and pediatric reference standards for comparisonXXX
      1.2BIdentifies and considers limitations of reference standards related to age, race, ethnicity, or genderXXX
      1.2CEstimates and modifies anthropometric measurements, as appropriate (eg, for physical or developmental disability, amputation[s], polycystic organs, or pregnancy)XXX
      1.2DIdentifies and interprets trends in anthropometric indices considering fluid status (eg, weight, growth, triceps skinfold, midarm muscle circumference, waist-hip ratio, conicity index)XXX
      1.2EEvaluates for significant changes in weight and body composition, including body habitus and weight distribution, and possible causesXX
      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 nutrition implications of diagnostic tests and therapeutic procedures:
      • diagnosis and staging of CKD (including eGFR
        eGFR = estimated glomerular filtration rate (as measured by blood analysis, 24-hour urinary creatinine clearance, or specialty testing such as Glofil)
        )
      • laboratory data for CKD-related complications such as anemia, CKD-MBD, fluid imbalance, hyperglycemia, dyslipidemia, and other nutrition-related biochemical parameters
      • blood pressure
      • neuropathy or retinopathy
      • Net Endogenous Acid Production (NEAP)
      • SGA
        SGA = subjective global assessment
        score or MIS
        MIS = malnutrition inflammation syndrome
      • transplant graft function
      • electrolyte abnormalities related to immunosuppression post-transplant
      Seeks assistance if needed
      XXX
      1.3BEvaluates adequacy of dialysis (eg, urea reduction ratio, urea kinetic modeling, or Kt/V
      Kt/V = a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy
      )
      XXX
      1.3B1Evaluates issues related to dialysis access and dialysis prescription that have potential to affect nutritional statusXX
      1.3B2Applies critical thinking and experience to evaluate inadequately delivered dialysis, including viability of dialysis access, prescription, and treatment modalityXX
      1.3CApplies critical thinking and experience to interpret results of tests, procedures, and evaluations; and to identify additional data to consider in assessmentX
      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
      1.4AEvaluates body composition measures validated for CKD populations (eg, fat and muscle stores, arm anthropometrics, SGA)XXX
      1.4BUses NFPE that includes, but is not limited to, oral and perioral structures; skin and related structures; alterations in taste, smell, and dentition/chewing ability to identify presence or risk of malnutrition or micronutrient deficienciesXXX
      1.4CUses critical thinking in the evaluation and physical assessment of fluid accumulation/edema in the CKD or ESKD
      ESKD = end-stage kidney disease (replacing older term of ESRD)
      patient (eg, type, location, measurement of edema)
      XX
      1.4DAssesses for clinical signs and symptoms of malnutrition (undernutrition), and eating disorders (eg, wasting of fat or muscle; dry, brittle, or thinning hair and nails; sarcopenia and cachexia; and decreased hand-grip strength or other measures of physical functioning related to nutrition)XX
      1.4EUses critical thinking and experience to evaluate physical assessment findings in the context of kidney disease and assessment data considerationsXX
      1.5Food and nutrition-related history assessment (ie, dietary assessment)

      Evaluates the following components:
      1.5AFood and nutrient intake including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Evaluates changes in appetite or usual dietary intake patterns and contributing factors (eg, as a result of uremia, oral aversion, altered taste acuity or perceptions, drug–nutrient interactions, pica behavior, adequacy of dialysis treatment, GI problems, comorbid conditions, hospitalization, transplant, or dialysis schedule/modality); seeks assistance if neededXXX
      1.5A2Assesses daily fluid needs, considering residual kidney function, medications, dialysis prescription and modality when applicable, post-transplantation graft function, physical activity, environmental conditions, and comorbid conditions; seeks assistance if neededXXX
      1.5A3Evaluates patient’s/client’s/advocate’s
      Advocate: An advocate is a person who provides support 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 Terms13 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation7).
      understanding of nephrology nutrition principles and ability to apply to food choices and meal planning
      XXX
      1.5A4Assesses food and nutrient intake considering the following:
      • stage of CKD, RRT,
        RRT = renal replacement therapy (hemodialysis, peritoneal dialysis, and transplantation)
        and life cycle stage
      • type and distribution of macronutrients and sources of protein
      • micronutrients (potassium, phosphorus, calcium, magnesium, sodium), comparing with evidence-based nutrition recommendations for individuals across the life cycle
      • adequacy of nutrient intake to maintain energy and nitrogen balance
      • history of food allergies/intolerances (eg, gluten sensitivity or intolerance, lactose intolerance)
      XXX
      1.5A5Assesses food and nutrient intake with an understanding of dietary modifications superimposed with comorbidities (eg, diabetes, CVD, CHF, infection, transplant)XX
      1.5BFood and nutrient administration including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Evaluates diet experience and current meal planning approach (eg, plate method, carbohydrate counting for diabetes), previous renal or other nutrition education/counseling and dietary modifications (eg, diabetes, hypertension, dyslipidemia, weight management)XXX
      1.5B2Evaluates eating environment, access, and cultural influences or differences (eg, location, atmosphere, family/caregiver/companion/eats alone, and types/preparation of cuisine)XXX
      1.5B3Evaluates need for nutrition therapy changes based on laboratory and physical indices and comorbidities; seeks assistance if neededXXX
      1.5B4Identifies need and timing for modification of nutrition plan (eg, transitions between feeding methods)XXX
      1.5B5Evaluates need for enteral nutrition/tube feeding or parenteral nutrition including intradialytic or intraperitoneal parenteral nutritionXX
      1.5B6Considers complex issues in the management of patients/clients with CKD/ESKD (eg, recovery from surgery/amputations/trauma/injury/illness, enteral or parenteral nutrition support, acute rejection post-transplantation, MIS) related to food intake, impact/changes in comorbid conditionX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Evaluates prescription or over-the-counter medications or dietary supplements, including, dose, timing, and adherence, in the context of CKD stage, RRT, and stage in life cycle:
      • phosphorus and potassium binders
      • potassium, magnesium, phosphorus, or calcium supplements
      • vitamin D analogs or calcimimetics
      • oral and injectable diabetes medications
      • antihypertensives
      • antihyperlipidemics
      • anti-rejection drugs
      • stool softeners/laxatives
      • vitamins and herbals
      Seeks assistance if needed
      XXX
      1.5C2Assesses safety, quality and efficacy of over-the-counter medications and dietary supplements; and evaluates actual or potential drug–nutrient and drug–drug interactions in consultation with pharmacist or other professionals, if indicated using database resources (eg, Natural Medicines Data base [https://naturalmedicines.therapeuticresearch.com/]); seeks assistance if neededXXX
      1.5C3Evaluates frequency and severity of changes in health status that require dietary supplements or medication adjustments (eg, hypo/hyperkalemia, hypo/hyperphosphatemia, hypomagnesemia, hyperparathyroidism, hyper/hypoglycemia)XXX
      1.5C4Evaluates overall medication management, including drug–drug/botanical and drug–nutrient interactions in collaboration with the interdisciplinary
      Interdisciplinary: The term interdisciplinary 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. Interdisciplinary could also mean interprofessional team or multidisciplinary team.
      team
      XX
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Evaluates behavioral mediators related to CKD and dietary intake (eg, knowledge, readiness and willingness to change, perceived or actual barriers, feelings about living with CKD, and caregiver influences on behavior)XXX
      1.5D2Evaluates self-care skills, behaviors, health care knowledge/beliefs/attitudes from the patient’s/client’s/caregiver's perspectiveXXX
      1.5D3Evaluates patient’s/client’s/advocate’s ability to identify evidence-based nutrition information among resources found in media and popular literatureXXX
      1.5D4Evaluates various influences (eg, language, physical activity, social networks, social or cultural norms and attitudes) that may impact behavior changeXXX
      1.5D6Assess risk/history of eating disorders or disordered eating pattern or factors, such as:
      • bingeing and purging behaviors (including fluids or ice)
      • abnormal mealtime behaviors (eg, drinking in place of eating, spitting out food, restrictive behaviors)
      • avoidance behavior (eg, eats alone, avoids social situations)
      • obsessive behaviors regarding meal composition
      XX
      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 food and water safety, access, barriers, and availability of healthy food/meals:
      • appropriate food preparation resources (eg, financial, food markets/grocery stores, and equipment for safe cooking, serving, and food storage)
      • food environment or access (eg, use of food pantry, meal programs, living situation, transportation)
      • water supply and source (eg, use of well water)
      • plans for emergency situations/disaster events (eg, availability of appropriate food, water, and supply of medications; communication routes or sources of information)
      • availability of family/caregiver to assist with obtaining/preparing food, if needed
      XXX
      1.5E2Investigates non-apparent barriers or conflicts that would interfere with food access, selection, preparationXX
      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
      1.5F1Assesses health literacy and numeracy (eg, ability to read, write, and perform calculations)XXX
      1.5F2Identifies factors or events that may impact patient’s/client’s physical and cognitive abilities (eg, hospitalization, amputation, retinopathy, uremia/inadequate dialysis, anemia, change in living situation or care provider support)XXX
      1.5F3Considers results from validated or commonly accepted developmental, functional, and mental status evaluation tools (eg, Karnofsky Performance Scale, Pediatric Quality of Life inventory ADLs, frailty assessment tools, depression screening tools) that reflect cultural, ethnic, and lifestyle factors in collaboration with the interdisciplinary teamXX
      1.5F4Considers changes in cognitive or physical functioning that may affect ability to meet nutrition goalsXX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.5G1Assesses patient’s/client’s/advocate’s understanding of health condition(s) and nutrition-related effects and implications as it relates to cultural, ethnic, and religious beliefs and traditionsXXX
      1.5G2Reviews/evaluates patient’s/client’s developmental, functional, cognitive status, and learning style/interactive abilities (visual, auditory, kinetic)XXX
      1.5G3Reviews/evaluates quality of life/end-of-life choices, including advanced directives or preferences relevant to the nutrition plan of careXXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patterns (eg, Academy, Academy EAL,
      EAL = Academy Evidence Analysis Library
      KDOQI,
      KDOQI = Kidney Disease Outcomes Quality Initiative
      KDIGO,
      KDIGO = Kidney Disease Improving Global Outcomes
      DOPPS,
      DOPPS = Dialysis Outcomes and Practice Patterns Study
      NHANES,
      NHANES = National Health and Nutrition Examination Study
      USRDS
      USRDS = US Renal Data System
      )
      XXX
      1.6AIdentifies and evaluates the most appropriate reference data or standards (eg, international, national, state, institutional, and regulatory) based on practice setting and patient-/client-specific factors (eg, age and disease state)XXX
      1.6A1Compares nutrition assessment data with appropriate criteria, population-based surveys, standards for determining nutrition-related recommendations for CKD stage, RRT, and life cycle stage:
      • energy needs/balance
      • macronutrient and micronutrient needs
      • fluid and electrolyte balance
      • mineral and bone disorder
      • adequacy of dialysis, when applicable
      Seeks assistance if needed
      XXX
      1.6A2Identifies reference standards to be included in organization’s/corporate’s/system’s assessment toolsXX
      1.6A3Recognizes and takes the lead in incorporating guidelines from other practice areas (eg, nutrition support, diabetes, pediatrics) into assessment guidelines and practices for renal care settings in collaboration with interdisciplinary teamX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7ACompares usual activity level with current age-appropriate physical activity guidelines (https://health.gov/our-work/physical-activity/current-guidelines)XXX
      1.7BAssesses effect of current treatment plan on usual activity level, ability to perform ADLs, and achievement of developmental milestones for pediatric populationXXX
      1.7CAssesses factors influencing access to physical activity (eg, environmental safety, walkability of neighborhood, proximity to parks/green space, access to physical activity facilities/programs)XXX
      1.7DEvaluates factors limiting physical activity (eg, vision, mobility, dexterity, neuropathy, or medication contraindications) and physical inactivity (eg, television/screen and other sedentary activity time)XXX
      1.8Collects data and reviews data collected 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 interdisciplinary team and other health care practitioners (eg, physician rounding or visit notes; nursing notes regarding fluid, potassium, and anemia management; social worker notes regarding mental health or access to food; dialysis treatment records)XXX
      1.8BReviews collected data from all sources to identify factors that impact nutrition and health status and CKD care and management in the context of interdisciplinary care:
      • complications of CKD, RRT, or post-transplantation
      • micro- and macrovascular complications of diabetes (eg, retinopathy, peripheral neuropathy, gastroparesis, wounds)
      • actual/potential GI side effects (eg, dry mouth, taste change, nausea or vomiting, constipation, or diarrhea)
      • behavioral health issues, including substance abuse
      • preventive care behaviors (eg, routine vaccinations, annual dental examinations, routine health screenings)
      • actual risk for cardiovascular complications (eg, hypertension, high ultrafiltration rate, intradialytic hypotension, CHF)
      • presence of barriers impacting treatment plans and outcomes (eg, finances/resources, transportation, communication, housing) nutrition concerns (eg, at-risk or with malnutrition, food insecurity)
      XX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AEvaluates and prioritizes nutrition-related problems (eg, intake, biochemical abnormalities, behavior change, weight change, findings from NFPE or SGA, malnutrition, physical activity, medication or treatment adherence) for factors that influence health and nutrition statusXXX
      1.9BEvaluates more complex issues related to food intake and clinical complications (eg, presence of nutrition risk factors or malnutrition and multiple complications) for prioritizing nutrition diagnosesXX
      1.9B1Evaluates complex food-, medication-, or treatment-related issues, clinical complications, and current or anticipated treatment options (eg, surgery, initiation of dialysis, modality change, transplant, withdrawal of treatment, or other medical management adjustments) in prioritizing nutrition problems in collaboration with the interdisciplinary teamX
      1.9CEvaluates and identifies nutrition risk factors for transplant (eg, malnutrition, obesity) in transplant candidatesXX
      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
      1.10E1Changes in patient/client/advocate level of understanding, food-related behaviors, readiness for change, other outcomes that dictate appropriate follow-up timing and effortXXX
      1.10FPatient/client adherence, as evidenced by biochemical/nutrition parameters and other indicatorsXXX
      1.10GInterest in kidney transplantation, or nutritional clearance and risk assessment for transplant eligibility listing when applicableXX
      1.10HReason for discharge/discontinuation or referral, if appropriateXXX
      1.10H1Pertinent nutrition information to coordinate care when status changes or patient/client transfers between settings (eg, discharge, transfer to another clinic, modality change, transplant, long-term care/skilled nursing or rehabilitation facility, daycare/school)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 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 in nephrology nutrition care and management.

      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
      2.1AUses evidence-based guidelines and protocols to organize and group data to formulate nutrition diagnosis(es); includes data relating to clinical and behavioral findings, physical function, and intake of food, nutrients, and fluidXXX
      2.1BConsiders complex data related to food intake and clinical condition, including preexisting factors, complex comorbidities (eg, diabetes, dyslipidemia, hypertension, abnormal eating habits, malabsorption syndromes, or psychiatric illness) and impact of other therapies and interventions (eg, bariatric surgery), and consults the interdisciplinary team or other providersXX
      2.1CIntegrates complex information related to food intake, biochemical data, diagnostic tests, therapeutic procedures, and clinical complications and their management with the interdisciplinary team or in consultation with other providersX
      2.2Prioritizes the nutrition problem(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
      2.2AEvaluates assessment data to prioritize nutrition diagnosis(es) in order of importance or urgency considering:
      • impact/urgency of the identified problem(s) (eg, inadequate protein or caloric intake; excessive fluid, carbohydrate, or mineral intake)
      • complications of comorbid diseases or conditions (eg, diabetes, hypertension, anemia, gastrointestinal disorders, cancer)
      • patient/client/advocate wishes and perception of importance, including palliative care
      • evidence-based protocols and guidelines
      • transplant candidacy
      • social determinants of health (eg, access to food, housing, access to care, social support)
      XXX
      2.2BPrioritizes nutrition diagnoses based on CKD and life cycle stage, RRT, comorbidities, complications, protocols, and guidelines for kidney disease and nephrology nutritionXX
      2.2CUnderstands the importance of considering the patient’s/client’s/ advocate’s goals and perceptions as key factors when prioritizing nutrition diagnosesXX
      2.2DPrioritizes nutrition diagnoses in the setting of CKD with secondary complications and comorbidities, using advanced clinical thinking, knowledge, and experienceX
      2.2ELeads interdisciplinary team discussions to address nutrition needs and plans of care for patients/clients with multiple complex care or transition of care issues to achieve positive outcomesX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriateXXX
      2.3ACommunicates and confirms nutrition diagnosis(es) with the patient/client/advocate, using appropriate communication methods and clinical judgment skills (eg, consideration of complications, wishes of patient/client/advocate), consistent with medical/treatment care planXXX
      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
      2.4AUses the electronic Nutrition Care Process Terminology (eNCPT) (https://www.ncpro.org/) for reporting diagnosis whenever possible (eg, imbalance of nutrients [NI-5.4], predicted inadequate energy intake [NI-1.4], impaired nutrient utilization [NC-2.1], increased nutrient needs [NI-5.1])XXX
      2.4BDocuments and explains nutrition diagnosis(es) in order of importance and in a manner that clearly describes the patient’s/client’s nutrition status and needsXXX
      2.5Reevaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AUses most current information that may impact nutrition diagnosis(es) and revises if needed in a timely manner (eg, changes in living arrangement or dialysis modality, laboratory/diagnostic tests, transplantation)XXX
      2.5BCommunicates new information with nutrition implications with the patient/client/advocate and with the interdisciplinary team and other health care practitioners (eg, behavioral, medical, physical/occupational therapist)XXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition Diagnostic Statements accurately, clearly, and concisely describe the nutrition problems of the patient/client or community
      • 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 problems, 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 evidence-based 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 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
      3.1APrioritizes nutrition diagnosis(es) considering one or more of the following based on CKD stage, RRT, and life cycle stage:
      • patient’s/client’s ability and willingness to implement and adhere to nutrition care plan
      • urgency of the problem and severity of nutrition risk or malnutrition, if present
      • presence of comorbid diseases or conditions (eg, including but not limited to prediabetes and diabetes, CVD, anemia, GI disorders, food allergies)
      • presence or risk of acute complications (eg, altered nutritional status, hypo/hyperkalemia, fluid imbalance, severe hypo/hypertension, hyper/hypoglycemia, metabolic acidosis/acidemia)
      • presence or risk for chronic complications or barriers to transplantation
      Seeks assistance if needed
      XXX
      3.1BConsiders needs related to transitions of care (eg, hospitalization, transplantation, subacute, rehabilitation, or long-term care facility, and changes in treatment modalities); seeks assistance if neededXXX
      3.1CPrioritizes considering medical issues (eg, presence or risk for CKD-MBD, anemia, MIS, left ventricular hypertrophy, altered nutritional status, altered weight status or growth velocity, micro/macrovascular disease), treatment goals, patient/client/caregiver/advocate preferences and goals for plan of careXX
      3.1DConsiders existence of or access to emerging therapies, including nontraditional intervention(s) (eg, integrative and functional medicine therapies or behavior modification)X
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2AIdentifies and applies appropriate adult and pediatric national/international evidence-based practice guidelines (eg, KDOQI, KDIGO, Academy’s EAL Nutrition Practice Guidelines, Adult and Pediatric Nutrition Care Manuals) and setting-specific clinical protocols (eg, anemia management, CKD-MBD, malnutrition, dialysis adequacy, potassium management)XXX
      3.2BRecognizes when it is appropriate and safe to deviate from established nephrology nutrition guidelines for person-centered care, including use of novel therapies, liberalized diet, or conservative management; seeks assistance if neededXX
      3.2CModifies application of kidney disease/nephrology nutrition guidelines based on the individual needs of the patient/client and progress of interventions, in collaboration with the interdisciplinary teamXX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interdisciplinary team, and other health care professionalsXXX
      3.4AServes as an integral member of the interdisciplinary teamXXX
      3.4A1Recognizes specific knowledge and skills of other providers, and collaborates to provide comprehensive careXXX
      3.4A2Teaches clinical practice skills and rationales for nutrition interventions to students/colleagues and interdisciplinary team membersXX
      3.4A3Directs nutrition interventions for kidney disease within context of complex disease management, in collaboration with the interdisciplinary teamX
      3.4BConsiders patient/client/advocate knowledge, self-care skills, behaviors/habits, and willingness to implement nutrition intervention to achieve goalsXXX
      3.4CRefers patient/client to appropriate health care provider for problems outside scope of practiceXXX
      3.4DMaintains communications with community setting (eg, assisted living/long-term care) or program(s) (eg, home care, home delivered meals) providing services for orientation/problem-solving on behalf of patient/clientXXX
      3.4ECoordinates and manages care with the patient/client/advocate in collaboration with interdisciplinary teamXX
      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 clear and measurable goals, outcomes, and plan(s) with patient/client/advocate through shared decision making and consideration of readiness to change and barriers to successful implementationXXX
      3.5BConsiders quality of life/end-of-life choices, including advanced directives or preferences in developing goals and the nutrition plan of careXXX
      3.5CConsiders patient/client/advocate understanding of CKD treatment options (dialysis modality, transplant, conservative management, palliative care) and their effects on nutrient needs and food choicesXX
      3.5DPlans nutrition interventions with the goal of minimizing treatment-related side effects, treatment delays, and the need for emergency department visits or hospital admission/readmissionXX
      3.5EDevelops and implements strategies to address lapses in self-care management or behaviors and identifies recovery strategiesXX
      3.5FDirects nutrition management of acute or long-term complications within the context of integrated care (eg, diabetes, CVD, surgery, infection, MIS, transplant)X
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6ADevelops or adjusts the nutrition prescription and intervention plan for CKD stage, RRT, and life cycle stage considering:
      • medical conditions, including food allergies/intolerances and treatment goals
      • nutrition diagnosis(es) and priority(ies)
      • usual nutrient/dietary intake patterns, including medical foods/nutrition supplements and calories absorbed from PD dialysate
      • cultural, religious, and other influences or beliefs
      • pharmacotherapy, including over-the-counter medications, and dietary supplements
      • route of nutrition, including enteral/parenteral nutrition therapies
      • physical activity, functional status, and psychomotor development
      • psychosocial and behavioral factors
      • nutrition counseling/education needs, including health literacy and numeracy, language barriers, and visual or hearing impairment
      • access to food, food preparation skills or assistance, and meals eaten away from home
      Seeks assistance if needed
      XXX
      3.6BCollaborates with patient/client/advocate to individualize the nutrition prescriptionXXX
      3.6CReviews medications commonly used in CKD (eg, mineral bone disorder, anemia management, growth failure, immunosuppression)XXX
      3.6C1Recognizes the impact and interactions of pharmacotherapy including dietary supplements, considering nutrition, physical activity, RRT, side effects, and biochemical markersXX
      3.6C2Recognizes need for adjustment of pharmacotherapy including dietary supplements based on integration of nutrition, physical activity, RRT, treatment schedule, personal routine, medication side effects, trough levels of immunosuppressive agents, and ongoing laboratory monitoring and response; and makes recommendations to the interdisciplinary team or physicianX
      3.6DRecommends plan for enteral/parenteral nutrition prescription collaborating with medical provider/interdisciplinary team as indicatedXXX
      3.6D1Recommends enteral nutrition/tube feeding or parenteral nutrition based on nutritional status, laboratory data, age, stage of CKD, and treatment modality; seeks assistance if neededXXX
      3.6D2Recommends modular components for enteral feedings as needed to meet nutritional needs and maintain optimal biochemical parameters (eg, protein status, potassium, phosphorus, calcium) and fluid balance; seeks assistance if neededXX
      3.6D3Recommends specialized nutrition support therapy (eg, intraperitoneal, or intradialytic parenteral nutrition); makes recommendations about formula composition in consultation with pharmacistXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7AUses evidence-based guidelines (eg, KDOQI, KDIGO, EAL) and regulatory guidelines (eg, Conditions for Coverage), individual needs, established goals and outcomes, and expected response to intervention(s) to determine duration and follow-upXXX
      3.7A1Considers expected changes in nutritional status and progress toward nutrition outcomes (eg, growth/ developmental changes, changes in feeding mode, re-assessment of transplant eligibility)XXX
      3.7A2Considers severity of nutritional issues, or pending medical or behavioral health interventions that are influenced by or may influence nutrition statusXX
      3.7A3Develops guidelines for timing of intervention and follow-up considering organization/program policies, CKD practice guidelines, and federal and state regulationsX
      3.8Uses standardized terminology for describing interventionsXXX
      3.8AUses the standardized terminology in the online eNCPT or follows facility/organization requirementsXXX
      3.9Identifies resources and referrals neededXXX
      3.9AIdentifies age and culturally-appropriate resources and tools to assist patient/client/advocate with management of CKD, or transplantation (eg, support groups, peer mentoring, transportation, health care services, meal programs, meal ingredient/delivery services, medication assistance programs, community outreach programs, education resources, online resources)XXX
      3.9BIdentifies and facilitates referrals to programs or providers (eg, transplant center, behavioral health, weight management/bariatric surgery program, endocrinologist, ophthalmologist, podiatrist, dentist, physical therapist, vocational rehabilitation) to assist patient/client/advocate with CKD-related issuesXXX
      3.9CCreates and maintains a list of nutrition and other resources specific to patient/client population in collaboration with interdisciplinary team members to support education and transitions of care/support from the communityXXX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interdisciplinary team, and other health care professionalsXXX
      3.10AFacilitates and fosters active communication, learning, partnerships, and collaboration with the nephrology team and other health care practitioners; seeks assistance if neededXXX
      3.10BRecommends to health care provider when medication adjustment is warranted (eg, based on biochemical indicators of CKD-MBD, chewing/swallowing ability, GI/tolerance issues, potassium management, anemia, glucose management); seeks assistance if neededXXX
      3.10CPartners or collaborates within an interdisciplinary team and with other providers as indicated to recommend changes to the renal protocols consistent with regulations and facility policies to manage nutrition-related conditions and support therapiesXX
      3.10DIdentifies and seeks opportunities for external and interagency collaboration, specific to the patient’s/client’s/advocate’s/caregiver’s needsX
      3.10EServes as resource to other practitioners and the interdisciplinary team on nutrition-related care and management for patients/clients with multiple complex medical conditionsX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11ACommunicates plan of care to interdisciplinary team and other health care professionals/agencies/facilities (eg, long-term care facility, assisted living) to coordinate nutrition careXXX
      3.11BEnsures communication of nutrition plan of care and transfer of related data between care settings (eg, home health, acute care, ambulatory care, transplant, dialysis facility, or long-term care facility) as neededXXX
      3.11CEnsures patient/client and, if applicable, advocate understands and can articulate goals and other relevant aspects of the plan of careXXX
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/nonphysician 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 qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.7,8 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 LTC 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.10,11Acronyms
      -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, or organizational policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diet, nutrition-related 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
      3.12A1iCollaborates with physician and interdisciplinary team to implement approved facility policies and protocols to address nutrition-related conditions, such as anemia, mineral and bone disorders, hypo/hyperkalemia, hypo/hyperphosphatemia, hypomagnesemia, and malnutrition and provide recommendations for use of medications, dietary supplements, and herbalsXX
      3.12A1iiUses advanced judgment and reasoning, which may include evaluation of data from laboratory monitoring, to adjust and implement pharmacotherapy plan following provider or facility-approved protocols and policiesX
      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
      3.12A2iCollaborates with physician and interdisciplinary team to manage enteral/parenteral nutrition and specialized nutrition support therapy (eg, intradialytic or intraperitoneal parenteral nutrition), including formula selection and adjustment based on laboratory results, consistent with privileges or physician-approved protocols or delegated ordersXX
      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
      3.12BIdentifies tools for nutrition education to support the intervention/ plan of care that are appropriate to the patient’s/client’s or advocate’s educational needs, developmental stage, learning style, and method of communication; uses interpersonal teaching, training, coaching, counseling, or technological approaches, as appropriateXXX
      3.12CIncorporates stages of behavior change as a guide to assess the patient’s/client’s readiness to learn and adjusts counseling style accordingly; includes family/caregiver as appropriate when working with children or individuals with special health care needs; seeks assistance if neededXXX
      3.12DFormulates and adapts nutrition education to the developmental stage of the patient/client and for advocate when applicable and makes changes to the intervention as appropriateXX
      3.12EUses experience, advanced knowledge, and critical thinking to individualize the treatment and education strategy for complex interventions in complicated, unpredictable, or dynamic situations (eg, complex comorbidities, medical or psychological instability)X
      3.13Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organizational policies/ protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical, and support personnelXXX
      3.13BProvides professional, technical, and support personnel with information and guidance needed to complete assigned activitiesXXX
      3.14Continues data collectionXXX
      3.14AIdentifies and records specific data collection for patient/client, including weight change, fluid balance, biochemical, behavioral, and lifestyle factors using prescribed/standardized formatXXX
      3.15Documents:
      3.15ADate and time and individuals involvedXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15C1Recommended and implemented interventions as applicable, as developed by the RDN and interdisciplinary teamXXX
      3.15DPatient/client/advocate/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPatient/client/advocate/caregiver/community comprehensionXXX
      3.15F1Understanding/comprehension of risks and benefitsXXX
      3.15GBarriers to changeXXX
      3.15G1Influencing factors or barriers affecting ability or willingness to implement and adhere to nutrition care plan (eg, living environment, psychosocial factors, emotional intelligence, cognitive development/impairment, change in mental or physical ability, financial status, access to food)XXX
      3.15HOther information relevant to providing care and monitoring progress over timeXXX
      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/Plan of Care
      • Goals and expected outcomes are appropriate and prioritized
      • Patient/client/advocate/population, caregivers and interdisciplinary teams collaborate and 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 with adjustment as needed
      • Nutrition intervention/plan of care is dynamic and is modified to help patient/client achieve optimal outcomes through progression of CKD, changes in RRT, and through the life cycle
      • 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 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
      4.1A1Verifies patient’s/client’s/advocate’s understanding of nutrition intervention by:
      • patient/client/advocate verbalization of goals
      • selection of appropriate foods, menus, or food preparation techniques
      • taking medications/dietary supplements as prescribed
      XXX
      4.1A2Determines whether barriers to understanding are present and impacting the patient’s/client’s/advocate’s acceptance of the nutrition intervention/plan of careXXX
      4.1A3Evaluates nutrition intervention that includes patient-/client-centered goalsXXX
      4.1A4Reassess patient’s/client’s stage of behavior change and learning style to evaluate need to revise nutrition intervention and plan of careXXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Communicates and collaborates with interdisciplinary team to monitor and assess progress with plan of care or evaluate reasons for lack of progress toward goalsXXX
      4.1B2Evaluates nutrition intervention in the face of multifactorial clinical situations (eg, malnutrition/protein energy wasting, food allergies and intolerances, and cultural factors along with multiple comorbid conditions); seeks assistance if neededXXX
      4.1B3Evaluates nutrition intervention in the face of complex clinical situations (eg, surgery/amputation, wounds, infection, transplantation, calciphylaxis, unstable blood glucose)XX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s) such as, but not limited to:XXX
      4.2A1Anthropometric measures (eg, weight, intradialytic weight gain, BMI, waist circumference, waist/hip ratio, rate of weight change, growth, and development)XXX
      4.2A2Body composition measures (eg, muscle and fat mass, triceps skinfold, midarm muscle circumference, hand grip strength)XXX
      4.2A3Laboratory measures (eg, albumin, nPCR
      nPCR = normalized protein catabolic rate
      /nPNA
      nPNA = normalized protein equivalent of nitrogen appearance
      , parathyroid hormone, calcium, phosphorus, potassium, carbon dioxide, sodium, glucose/hemoglobin A1c, lipids); seeks assistance if needed
      XXX
      4.2A4Quality of life measures (eg, KDQOL scores, Pediatric Quality of Life score, activities of daily living)XXX
      4.2A5Treatment-related markers or test results (eg, Kt/V or urea reduction ratio, ultrafiltration rate, peritoneal equilibration test, access flow, immunosuppression); seeks assistance if neededXXX
      4.2A6Treatment or disease state markers in complex clinical situations (eg, calcific uremic arteriolopathy, acute graft rejection, autoimmune disorders)XX
      4.2A7Health care utilization measures for nutrition and CKD management outcomes (eg, consistent delivery or access to care, treatment-related side effects, incidence of infections and hospitalizations, and resource utilization)X
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Documents progress in meeting goals and desired clinical and lifestyle outcomesXXX
      4.2B2Identifies unintended consequences, use of inappropriate methods of achieving goals (eg, erratic use of medications or dietary supplements, self-imposed dietary restrictions), and actual or potential adverse effects related to complex problems and interventionsXX
      4.2CMonitors intended effects and potential adverse effects of pharmacological and nonpharmacological treatment (eg, unintentional weight loss, biochemical abnormalities)XXX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Compares individual patient/client data trends with accepted targets based on national, state, and local public health and population-based data (eg, ESRD
      ESRD = end-stage renal disease (increasingly replaced by ESKD)
      Networks, USRDS, DOPPS, NAPRTCS,
      NAPRTCS = North American Pediatric Renal Trials and Collaboration Studies
      MAT,
      MAT = measurement assessment tool
      HP2020
      HP2020 = Healthy People 2020
      )
      XXX
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Assesses need for continuation of interventions based on outcomes and clinical data (eg, weight or biochemical parameters stable within desired range necessitating reevaluation of need for nutrition supplement or parenteral nutrition) with interdisciplinary teamXXX
      4.3B2Completes comprehensive analysis of indicators for each identified problem compared with protocols and reference standards for impact on patient/client health outcomes and goalsXX
      4.3B3Completes a trending analyses of the indicators and how they correlated with each other, to determine and evaluate the complexity of problems and influence on patient/client/population health outcomesX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Elicits feedback from patient/client/advocate about progress with nutrition- or health-related behavior changeXXX
      4.3C2Applies theories of behavior change to evaluate and address progress/lack of progress with goals and interventionsXXX
      4.3C3Consults with the interdisciplinary team and other health care practitionersXXX
      4.3C4Uses multiple resources to assess progress (eg, NFPE, laboratory and other clinical data, changes in body weight/body composition, pertinent medications/dietary supplements) relative to effectiveness of the care planXX
      4.3C5Leads discussions with the IDT to address needs and interventions for patients/clients with complex needsX
      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
      4.3D1Identifies appropriate sources for evidence of problems or adherence (eg, food choices, food logs, 24-hour food recall, laboratory results, objective data, NFPE/SGA)XXX
      4.3D2Uses direct observation, interview, or other methods to evaluate patient/client outcomes (eg, laboratory data, self-monitoring of blood glucose results, treatment data, physical, social, cognitive, environmental factors, ADLs, and growth and development) that explain lack of response or could influence response to nutrition interventionXXX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Clearly identifies subjective and objective patient-/client-centered evidence to support conclusionsXXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interdisciplinary teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based on outcomes data, trends, best practices, and comparative standardsXXX
      4.4BAdjusts intervention strategies as needed to address individual patient/client needs (eg, change in CKD stage or RRT, changes in medications, change in living/care situation, progress/change in goal, change in health status, change in functional status); seeks assistance if neededXXX
      4.4CAddresses underlying factors interfering with meeting the CKD and nutrition intervention goals (eg, access to resources, lack of insurance, cost of medications, treatment adherence)XXX
      4.4DModifies intervention strategies as appropriate to address patient/client needs, new/emerging situations (such as comorbidities and complications), and results of any further testing or change in treatment modalityXX
      4.4EArranges for additional resources and support services (eg, training of direct care providers, collaboration with health care professionals) for implementing nutrition intervention/plan of care with patient/client/advocate, balancing multiple situations (eg, emergency situations, or clinical complications)XX
      4.4FTailors tools and methods to ensure desired outcomes reflect the patient’s/client’s developmental age, social, physical, environmental factors, and CKD nutrition and treatment goalsXX
      4.4GAdjusts intervention strategies by drawing on practice experience, knowledge, clinical judgment, and research-/evidence-based practice about the patient/client populations in complicated and unpredictable situations (eg, pregnancy, eating disorders, cancer, pediatric conditions, gastroparesis)X
      4.5Documents:XXX
      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
      4.5C1Reviews, understands, and documents criteria to which the indicator is compared (ie, nutrition prescription/goal, reference standard, or clinical judgment)XX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5FAdjustments to the nutrition intervention/plan of care, if indicated, reflecting involvement of interdisciplinary teamXXX
      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, RRT choice/progression, 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 Advocate: An advocate is a person who provides support 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.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation
      State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      ).
      B Interdisciplinary: The term interdisciplinary 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. Interdisciplinary could also mean interprofessional team or multidisciplinary team.
      C 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 qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
      State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      ,
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
      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 LTC 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.
      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#2016; 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). 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.
      Acronyms
      a CVD = cardiovascular disease
      b CHF = congestive heart failure
      c GI = gastrointestinal
      d KDQOL = Kidney Disease Quality of Life Survey
      e CKD-MBD = chronic kidney disease-mineral and bone disorder
      f eGFR = estimated glomerular filtration rate (as measured by blood analysis, 24-hour urinary creatinine clearance, or specialty testing such as Glofil)
      g SGA = subjective global assessment
      h MIS = malnutrition inflammation syndrome
      i Kt/V = a number used to quantify hemodialysis and peritoneal dialysis treatment adequacy
      j ESKD = end-stage kidney disease (replacing older term of ESRD)
      k RRT = renal replacement therapy (hemodialysis, peritoneal dialysis, and transplantation)
      l EAL = Academy Evidence Analysis Library
      m KDOQI = Kidney Disease Outcomes Quality Initiative
      n KDIGO = Kidney Disease Improving Global Outcomes
      o DOPPS = Dialysis Outcomes and Practice Patterns Study
      p NHANES = National Health and Nutrition Examination Study
      q USRDS = US Renal Data System
      r nPCR = normalized protein catabolic rate
      s nPNA = normalized protein equivalent of nitrogen appearance
      t ESRD = end-stage renal disease (increasingly replaced by ESKD)
      u NAPRTCS = North American Pediatric Renal Trials and Collaboration Studies
      v MAT = measurement assessment tool
      w HP2020 = Healthy People 2020
      Figure 2Standards of Professional Performance for RDNs in Nephrology Nutrition.
      Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean 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 Nephrology 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 Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to their area(s) of practiceXXX
      1.1AComplies with state licensure or certification laws and federal or state regulations, if applicable, including telehealth and continuing education requirementsXXX
      1.1BComplies with applicable federal or state regulations, accreditation standards, and payment policies for providers and institutions/programsXXX
      1.2Performs within individual and statutory scope of practice and applicable federal or state laws and regulations, accreditation standards, or applicable nephrology standardsXXX
      1.2AUnderstands and works within scope of practice in nephrology nutrition; assures:
      • job description/contract specifications comply with defined scope of practice, employer requirements, identified role, and professional responsibility
      • consistency with credentialing requirements (eg, Board Certified Specialist in Renal Nutrition [CSR] or Pediatric Nutrition [CSP], Certified Diabetes Care and Education Specialist [CDCES], Certified Clinical Transplant Dietitian [CCTD])
      XXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3AEnsures ethical and accurate reporting and billing of nephrology nutrition services (eg, MNT,
      MNT = medical nutrition therapy.
      kidney disease education, diabetes management/education)
      XXX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum [NQF], Institute for Healthcare Improvement, NIH,
      NIH = National Institutes of Health.
      KDIGO,
      KDIGO = Kidney Disease: Improving Global Outcomes.
      KDOQI,
      KDOQI = Kidney Disease Outcome Quality Initiative.
      HP2020
      HP2020 = Healthy People 2020.
      ) to improve the quality of services provided and to enhance customer-centered services
      XXX
      1.4AReflects national standardized and consensus-based nephrology guidelines in policies and procedures and other programs (eg, CMS,
      CMS = Centers for Medicare and Medicaid Services.
      KDOQI, KDIGO, EAL
      EAL = Academy of Nutrition and Dietetics Evidence Analysis Library.
      )
      XXX
      1.4BParticipates or leads organization/renal network quality initiatives related to nephrology nutritionXX
      1.4CMonitors changes to local, state, renal network, and national quality initiatives and leads quality improvement activities to support nephrology nutrition and related servicesX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AUses the organization/department performance improvement process to collect data and measure performance against desired outcomesXXX
      1.5BObtains training and mentors members of the interdisciplinary
      Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, nurse practitioners, pharmacists, psychologists, social workers, dialysis technicians, medical assistants, and occupational and physical therapists), depending on the needs of the patient/client/customer. Interdisciplinary could also mean interprofessional or multidisciplinary.
      team on performance improvement model(s) and leads performance improvement initiatives
      XX
      1.5CDevelops and leads interdisciplinary quality improvement activities across the organization or systemX
      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 interdisciplinary efforts to monitor and improve nephrology outcomesXXX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies quality outcomes and defines targets for the population/organization/program through evaluation, benchmarking, and monitoring environmental trendsXX
      1.6B2Leads the development of clinical measures from which nephrology nutrition care-related outcomes can be derived, reported, and used for improvementX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Identifies and uses nationally standardized and consensus-based nephrology performance measures (eg, MAT,
      MAT = measurement assessment tool.
      CMS 5-Star,
      5-Star = CMS Five-Star Quality Rating System.
      QIP
      QIP = quality incentive program.
      )
      XXX
      1.6C2Selects criteria for data collection and participates in the development of data collection tools (eg, clinical, operational, financial)XX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Uses systematic quality improvement approaches to collect and trend data regarding the population served (eg, demographics, acuity, clinical risk factors, morbidity, and mortality), services provided, and outcomesXXX
      1.6D2Routinely assesses services using culturally competent engagement process in accordance with established performance criteria to improve practice and nephrology nutrition careXX
      1.6D3Develops or uses systematic processes or tools to monitor and analyze nephrology nutrition-related aggregate data in comparison to expected outcomesX
      1.6D4Mentors practitioners in measuring nephrology processes to evaluate effectivenessX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6E1Ensures that screening for nutrition risk is a component of program admission process or nutrition assessment using evidence-based screening tools for the setting or populationXXX
      1.6E2Collects data using clinical quality measures applicable to population and setting (eg, screening timeframes, severity of malnutrition, and services provided [eg, nutrition assessment, nutrition or dietary supplements, nutrition counseling])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
      1.6F1Documents outcomes related to patient-/client-reported quality of life, depression, or other indicators (eg, KDQOL,
      KDQOL = Kidney Disease Quality of Life Survey.
      PHQ-2
      PHQ-2 = Patient Health Questionnaire-2 for mental health screening.
      ) and participates in evaluation and reporting
      XXX
      1.6F2Collaborates with RDN colleagues in local/system nephrology programs to collect data for documenting and reporting outcomes of nutrition interventionsXX
      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
      1.6G1Actively promotes the inclusion of RDN-provided MNT and nephrology nutrition service components in local, regional, or national nephrology and transplant data registriesXX
      1.6G2Analyzes and uses information for long-range strategic planning (eg, program and service efficacy)X
      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
      1.7AEvaluates and ensures safe nephrology nutrition care delivery; seeks assistance if neededXXX
      1.7BKeeps up-to-date on current findings regarding dietary supplements (eg, Natural Medicine Database [https://naturalmedicines.therapeuticresearch.com/], MedWatch, Nutrition.gov: Dietary Supplements), and food safetyXXX
      1.7CIdentifies and educates patients/clients/families and interdisciplinary team regarding potential drug-food/nutrient and drug-dietary supplement (eg, vitamin, mineral, herbal) interactions; consults with pharmacist as neededXXX
      1.7DReports errors, hazards, or near misses; refers patients/clients to appropriate services when error or hazard is outside of practitioner’s scope of practice or experienceXXX
      1.7EMaintains awareness of problematic product names, drug classes, and error-prevention recommendations provided by ISMP,
      ISMP = Institute for Safe Medication Practices.
      FDA,
      FDA = Food and Drug Administration.
      and USP
      USP = US Pharmacopeial Convention.
      XX
      1.7FCollaborates with the interdisciplinary team and other providers to recognize potential drug–drug and drug–nutrient interactions and potential interactions between prescribed treatments and integrative and functional medicine therapiesXX
      1.7GContributes to developing/maintaining systems to identify, monitor, prevent, and report medical errors, sentinel events, and near misses (eg, medication, treatment, infection control)X
      1.8Compares actual performance to performance goals (eg, 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 or service performanceXXX
      1.8BEvaluates individual and organization performance in comparison with goals and expected outcomes; contributes to or develops action plans to address identified gapsXX
      1.8CBenchmarks department/organization performance with national programs and standardsX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AConducts data analysis to evaluate the success of action plans in meeting patient/client and program goals, develops report of outcomes, and provides recommendationsXX
      1.9BGuides the development, evaluation, and redesign of organization/ program evaluation systemsX
      1.10Improves or enhances patient/client/population care or services working with others based on measured outcomes and established goals using culturally competent engagement processesXXX
      1.10ASystematically reviews nutrition care or services to identifying problem areas and recommends improvements to practiceXXX
      1.10BLeads or collaborates in creating and evaluating systems, processes, and programs that support organization nephrology nutrition-related core values and evidence-based guidelines for safe, quality careXX
      1.10CDevelops or investigates systems, processes, and programs that support best practices in nephrology nutrition care and services; publishes outcomes and best practicesX
      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 systems specific to program(s)/service(s) are established and updated as needed; are 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 preestablished 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 Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic Registration [CDR], other national organizations, 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 and/or SOPP into practice (www.eatrightpro.org/sop) (eg, Pediatric Nutrition, Diabetes Care, Post-Acute and Long-Term Care Nutrition)XXX
      2.2BUses the Standards for Nephrology Nutrition to assess performance at the appropriate level of practice and develop a professional development plan to advance skills/practiceXXX
      2.2CReviews and recommends updates to organization policies, guidelines, or materials (eg, job descriptions, performance competencies, career ladders, acceptable performance level) reflecting the SOP and SOPP for RDNs in Nephrology Nutrition; seeks assistance and approvals, if neededXX
      2.2DUses advanced practice experience and knowledge to define specific activities for levels of practice (competent, proficient, expert) reflecting the SOP and SOPP for RDNs in Nephrology NutritionX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ADocuments examples of expanded professional responsibility reflective of proficient practice (eg, evaluates the delivery of customer-centered services provided and recommends changes)XX
      2.3BDocuments examples of expanded professional responsibility reflective of expert practice (eg, evaluates and develops practice and delivery models for customer-centered services; quality assurance and performance improvement [QAPI] leadership responsibilities; corporate/system level role[s])X
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BExhibits professionalism and strives for improvement in practice (eg, manages change effectively, demonstrates assertiveness, listening and conflict resolution skills, and demonstrates ability to build coalitions)XXX
      2.4CRecognizes strengths and limitations of current information/ research/evidence when making recommendations; seeks assistance if neededXXX
      2.4DDevelops and implements nephrology nutrition-related policies and procedures that ensure staff accountability and responsibility; collaborates with interdisciplinary team or seeks guidance if neededXX
      2.4ELeads by example; exemplifies professional integrity as a leader of nephrology nutrition by serving as a resource for evidence-based practice and educating members of the interdisciplinary team/organizationX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional development (eg, feedback from peers, interdisciplinary team members, patients/clients; comparison to SOP and SOPP indicators; published nephrology nutrition practice guidelines; or the Nephrology Nutrition Content Outline/Test Specifications provided with the Certified Specialist in Renal Nutrition [CSR] credentialing examination review materials)XXX
      2.5BCompares individual performance with personal goals and for consistency with best practices in nephrology nutrition practice to identify areas for professional growth and developmentXXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organization policies and procedures, credentialing agency[ies])XXX
      2.6A1Designs and implements a continuing education plan for advancing nephrology nutrition knowledge and skills (eg, serves on an editorial board or participates in scholarly review of professional or practice articles, books or chapters; establishes/leads a journal club for IDT or department; participates in grand rounds)XX
      2.6A2Designs and implements an expert-level plan for professional growth and development (eg, leads an editorial board, serves on a work group for development of evidence-based practice guidelines; serves as a subject matter expert in an organization initiative)X
      2.6BSeeks opportunities to participate in continuing education in local, regional, national, or international settingsXXX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AReads nephrology nutrition-related peer-reviewed publications and participates in continuing educationXXX
      2.7BUses knowledge and experience to implement and communicate best practicesXX
      2.7CUses advanced training, research, and emerging theories to manage complex cases (eg, multiple comorbidities, complications) in the CKD
      CKD = chronic kidney disease.
      population
      X
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer review activities consistent with setting and patient/client population (eg, peer evaluation, peer supervision, clinical chart review, and performance evaluations)XX
      2.8BDesigns or leads peer-review process(es) or activitiesX
      2.9Mentors or precepts othersXXX
      2.9AParticipates in mentoring/precepting nutrition and dietetics students/interns; seeks assistance if neededXXX
      2.9BPursues mentoring relationships and precepting opportunities with credentialed nutrition and dietetic practitioners and nutrition and dietetics students/interns from marginalized populationsXXX
      2.9CFunctions as a mentor or preceptor in nephrology nutrition for entry-level and competent-level RDNs and nutrition and dietetics students/internsXX
      2.9DDevelops or directs mentoring or practicum opportunities for RDNs to support achieving proficient-level practice or specialist certification in nephrology nutritionXX
      2.9EFunctions as a mentor or preceptor in nephrology nutrition for competent- and proficient-level RDNs or health care practitioners of other disciplineX
      2.9FProvides nephrology nutrition expertise and counsel to education programs related to food and nutrition care and services, industry standards, practice guidelines, and practice roles for nutrition and dietetics practitionersX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice settingXXX
      2.10ACompletes pertinent nephrology-related education and skill development opportunities; see Figure 4XXX
      2.10BObtains and maintains specialist credentials(s) (eg, CSR, CDCES, CSP, CCTD, RDN-Advanced Practitioner Certification in Clinical Nutrition [RDN-AP])XX
      2.10CDevelops programs, tools, and resources to support RDNs in obtaining specialty certification in nephrology nutritionX
      2.10DIntegrates nephrology practice with other focus areas of practice using national standards (eg, diabetes, nutrition support, pediatrics)X
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • Code(s) of ethics (eg, Academy/CDR, other national organizations, 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 Indicators
      The “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
      3.1A1Participates in strategic activities for nephrology nutrition programs (eg, program planning, staffing, marketing, budgeting, billing, if applicable)XX
      3.1A2Develops and manages nutrition programs tailored to the needs of the organization and the patient/client populationXX
      3.1A3Designs, promotes, and seeks executive and/or medical staff commitment to new services that will meet organization goals and support desired nutrition outcomesX
      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
      3.1B1Conducts ongoing assessment of the nephrology and health care environments identifying opportunities to develop and deliver education, screening, and prevention services related to kidney diseaseXXX
      3.1B2Collaborates with local and regional programs that support and optimize provision of nephrology services (eg, health departments, volunteer organizations, networks)XX
      3.1B3Leads in the evaluation, development or modification, and dissemination of appropriate products and services to meet patient/client population needsX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Advocates for staffing and resources that support patient/client population, census/caseload, acuity, programs, services, and goalsXX
      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, gender, socioeconomic status, age, health literacy, and other factorsXXX
      3.1D2Develops programs and services that are tailored to patient/client population characteristics, disease states, health status, and social determinants of healthXX
      3.1D3Evaluates effectiveness of and revises programs and services for continuous improvement of outcomesX
      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
      3.2A1Participates in or develops processes to receive or make referrals to other providers that address the needs of the CKD population (eg, pharmacist, mental/behavioral health professional, physical therapist, speech language pathologist, vascular surgeon/center, transplant center, bariatric surgery center)XX
      3.2A2Directs, manages, and evaluates referral processesX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Verifies potential referral provider’s care reflects evidence-based information/research and professional standards of practiceXXX
      3.2B2Collaborates with health care practitioners to facilitate referrals when patient/client need(s) is outside the RDN’s scope of practice (eg, mental/behavioral health professional, exercise physiologist/physical therapist, podiatrist, dentist, pharmacist, ophthalmologist, bariatric/vascular access/transplant center)XXX
      3.2B3Establishes and maintains networks to support the overall care of the patients/clients with CKDXX
      3.2B4Supports referral resources with curriculum and training regarding the complex needs of patients/clients with CKDX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate efficiency and effectiveness of the nutrition referral processXX
      3.2C2Collaborates with the interdisciplinary team and other health care providers to review data and update the nutrition referral process and tools when neededXX
      3.2C3Provides organization/program data needed to improve/update the nutrition-related information included in referralsX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Recognizes the influence that culture, health literacy, and socioeconomic status have on health/illness experiences and the patient/client population’s use of and access to health care servicesXXX
      3.3A2Applies goal setting and behavior change strategies and techniques (eg, stages of change/transtheoretical model, motivational interviewing) in gathering information to reflect in design of person-centered servicesXXX
      3.3A3Conducts needs assessment considering social determinants of health in collaboration with interdisciplinary team and community stakeholders to identify patient/client population’s needs and services that are availableXX
      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 nephrology populationXXX
      3.3B2Participates in or plans, develops, and implements systems of care and services reflecting needs of the population (health conditions, ethnic/cultural characteristics)XX
      3.3B3Leads in applying, evaluating, and communicating the effectiveness of different theoretical frameworks for interventions (eg, health belief model, social cognitive theory/social learning theory, stages of change/ transtheoretical model) in nephrology nutritionX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Identifies patient/client population’s cultural or health-related beliefs regarding CKD that influence delivery of nephrology nutrition education and careXXX
      3.3C2Advises on and uses systems or tools for communicating disease prevention and behavioral change principles with specific populationsXX
      3.3C3Designs systems or tools to communicate disease prevention and behavioral change with specific populationsX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Collaborates with patients/clients/caregivers, health care providers, and other support resources to create person-centered action plans that reflect the patients’/clients’ needs, wishes, desired outcomes, and program/service goalsXXX
      3.3EInvolves customers in decision makingXXX
      3.3E1Uses appropriate tools such as motivational interviewing to involve patients/clients advocates in directing nephrology nutrition careXXX
      3.3E2Facilitates patients’/clients’/advocates’ participation in health care decision making and goal settingXXX
      3.4Executes programs/services in an organized, collaborative, cost effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interdisciplinary teamsXXX
      3.4A1Works with interdisciplinary team for education/skill development and to demonstrate role of RDN and nutrition in care of individuals with CKDXXX
      3.4A2Collaborates with interdisciplinary team and other health care practitioners to:
      • plan and deliver appropriate products and services (eg, medical foods/nutrition supplements, referrals to specialists, use of community resources)
      • provide education or community programs
      XXX
      3.4A3Serves in a consultant role for nutrition management of CKD and comorbiditiesXX
      3.4A4Facilitates interdisciplinary discussions and care planning for patients/clients with complex nutrition needs to achieve nutrition outcomes (eg, acute transplant rejection, hepatorenal syndrome, cardiorenal syndrome, post-bariatric surgery)XX
      3.4A5Plans, develops, and facilitates interdisciplinary process for implementation of systems/programs for nephrology 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, and grant management)XXX
      3.4B1Incorporates standards for nephrology nutrition care based on evidence-based guidelines and recommendations in the design of programs and services; seeks assistance if neededXXX
      3.4B2Identifies and uses population-specific nutrition and nephrology screening guidelines and toolsXXX
      3.4B3Manages delivery of nephrology nutrition care and services as an active participant in interdisciplinary teamsXXX
      3.4B4Implements and manages community-based CKD nutrition education/prevention programs, using evidence-based strategies and available resourcesXX
      3.4B4iPlans and develops population-based CKD nutrition and health promotion/prevention programs, using evidence-based strategies and available resourcesX
      3.4B5Guides the development, implementation, and evaluation of nephrology nutrition care, programs, screening initiatives, and services for individuals with or at risk for CKDX
      3.4CUses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning/transitions of care, emergency planning), protocols, standards of care, technology resources (eg, Health Insurance Portability and Accountability Act [HIPAA]-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Participates in the development and revision of policies, procedures, and evidence-based practice tools for nephrology nutrition-related services applicable to population served by setting(s)XXX
      3.4C2Develops or maintains nephrology nutrition protocols, policies and procedures based on research, national and international evidence-based guidelines, and best practicesXX
      3.4C3Leads interdisciplinary process of monitoring, evaluating, improving, and implementing protocols, guidelines, and practice toolsX
      3.4C4Participates in or leads in the development of provider-, facility-, or organization-approved clinical protocols guiding delivery of care (eg, medical food/nutritional supplements, dietary supplements, CKD-MBD management, or dialysis adequacy)X
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff
      Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.7
      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
      Nonphysician practitioner: A nonphysician 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 qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.7,8 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 LTC 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.10,11Acronyms
      -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
      3.4D1iAdheres to provider- or organization-approved protocols or privileges for ordering therapeutic diets and nutrition-related services (eg, oral nutrition supplements; vitamins/minerals; to initiate/titrate medication for management of phosphorus, or chronic kidney disease-metabolic bone disease [CKD-MBD]); seeks assistance if neededXXX
      3.4D1iiContributes to organization/medical staff process for identifying RDN privileges or delegated orders to support nephrology nutrition care and services (eg, ordering or revising diet, medical food/nutritional supplements, enteral or parenteral nutrition, vitamin and mineral supplements, or other nutrition-related orders)XX
      3.4D1iiiAdvocates, negotiates, or establishes nutrition privileges at a systems level for new advances in practiceX
      3.4D2Uses and participates in, collaborates with, 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
      3.4EComplies 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
      3.4E1Develops tools to monitor adherence to billing regulations and ethical billing practicesXX
      3.4FCommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s personal health information (PHI)XXX
      3.4F1Follows regulations and organization/program policies for accessing, transporting, and storing information containing PHI when working in multiple sites; seeks assistance if neededXXX
      3.4F2Develops processes and tools to monitor adherence to HIPAA rules or address breaches in the protection of PHI and use of electronic medical records (onsite or through remote access)XX
      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
      3.5A1Determines capabilities/expertise of professional, technical, and support staff working with patients/clients with CKD to appropriately delegate tasksXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates and documents their competence/skillsXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      3.6ACollaborates in or leads the design of food delivery systems to address health care needs and outcomes (including nutrition status) and ecological sustainability, and to meet the culture and related needs and preferences of target populations (eg, 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 provides feedback on food delivery systems serving individuals with CKD in health care and community settings (eg, hospital, long-term care facility, outpatient ambulatory care facilities, senior center, food banks/pantries, home delivery, school or childcare sites)XXX
      3.6A2Evaluates effectiveness of foodservice planning and delivery for patients/clients with CKD to identify areas for improvement applicable to setting and roleXX
      3.6A3Consults on design, evaluation, or modification of food delivery systems in health care and community settings (eg, meal programs, food banks/pantries serving food insecure) to identity and support the needs of the CKD populationX
      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
      3.6B1Participates in development or provides consultation on menu systems to meet needs of individuals with CKD across the life cycleXX
      3.6B2Develops nephrology nutrition-related menu/snack guidelines reflecting national standards/guidelines (eg, National Kidney Diet, KDOQI, EAL, NCM
      NCM = Academy of Nutrition and Dietetics Nutrition Care Manuals (adult and pediatric).
      ) and applicable federal or state regulations to guide foodservice program(s) for populations served
      X
      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 medical foods/nutritional supplements, enteral or parenteral nutrition formulas including IDPN
      IDPN = intradialytic parenteral nutrition.
      and IPN
      IPN = intraperitoneal nutrition.
      in accordance with best practice for the spectrum of CKD (eg, Academy, ASPEN,
      ASPEN = American Society for Parenteral and Enteral Nutrition.
      NKF
      NKF = National Kidney Foundation.
      )
      XX
      3.6C2Designs or consults on organization policies, procedures, protocols, or programs to provide guidance for nutrition support best practices for individuals with CKDX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems including electronic health recordsXXX
      3.7A1Promotes use of standardized terminology and documentation formatXXX
      3.7A2Uses and participates in the development/revision of electronic health records applicable to setting and strategies for manual documentation as a backupXXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Develops or collaborates with the interdisciplinary team to capture nephrology-specific data through electronic health records or other data-collection toolsXX
      3.7B2Develops policies for data collection and analysis processX
      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
      3.7C1Analyzes and uses data to communicate value of nutrition services in relation to patients/clients and organization outcomes/goalsXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Prepares and presents nutrition care service and outcomes data for organization and accreditation organization if applicable; seeks assistance if neededXX
      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
      3.8A1Considers organization policies related to participating in advocacy activitiesXXX
      3.8A2Advocates with state and federal legislative representatives regarding the benefit of MNT/CKD management and prevention services on health care costs (eg, responds to Academy Action Alerts and other calls to action)XXX
      3.8A3Contributes to or initiates advocacy activities/issues at the local, state or federal level; recruits/coordinates others in advocacy activitiesXX
      3.8A4Advocates for the advancement of nephrology-related nutrition practice to external stakeholders (eg, CMS, state licensure boards, ESRD
      ESRD = End Stage Renal Disease (increasingly being replaced by End Stage Kidney Disease [ESKD]).
      Networks, and the Academy’s Policy Initiatives and Advocacy 0ffice)
      XX
      3.8A5Interacts and serves as a resource with legislators, payers, and policy makers to influence CKD care and nephrology nutrition services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8A6Provides leadership to colleagues (RDNs, community members, other stakeholders) on nutrition and public policyX
      3.8A7Contributes to development/review/comments/ recommendations on policy, statutes, administrative rules and regulationsX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Participates in CKD population advocacy activities (eg, community screenings; local NKF, AKF,
      AKF = American Kidney Fund.
      or association events; CKD outreach education programs)
      XXX
      3.8B2Identifies needs and opportunities for CKD population advocacy and participates in efforts to address issue(s)XX
      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
      3.8C1Participates in regional or national activities related to nephrology or nutrition policy and services; seeks opportunities for collaborationXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, values, and customer needs and expectations
      • Customers participate in establishing program/service goals and customer-focused action plans 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, 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, 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 Indicators
      The “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
      4.1BReads primary peer-reviewed publications pertaining to nephrology and nutrition; evaluates research design, methodology, and outcomes to determine reliability and practice applicationsXXX
      4.1CUses and promotes the use of evidence-based tools/resources (eg, EAL, practice guidelines) to guide clinical practiceXXX
      4.1DUses experience and critical thinking to evaluate strength of original research and evidence-based guideline relevant to nephrology nutrition, including limitations and potential bias(es)XX
      4.1EEvaluates and applies nephrology-related public health trends and epidemiological data related to CKD prevention, treatment, and underlying causes (eg, USRDS,
      USRDS = US Renal Data System.
      HP 2020, DOPPS,
      DOPPS = Dialysis Outcomes and Practice Patterns Study.
      SRTR
      SRTR = Scientific Registry of Transplant Recipients.
      )
      XX
      4.1FIdentifies nephrology nutrition questions and uses a systematic approach for applying research and evidence-based guidelines (eg, EAL, KDQOI, KDIGO)X
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2ASystematically reviews and applies the best available research where evidence-based practice guidelines for nephrology are not establishedXX
      4.2BIntegrates research findings and evidence into peer-reviewed publications and recommendations for practiceX
      4.2CMentors others in applying evidence-based research and guidelines for practiceX
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AApplies evidence-based practice guidelines (eg, EAL, KDOQI, KDIGO) to provide safe, effective, and quality person-centered nutrition care for the CKD patient/client populationXXX
      4.3BManages the integration of evidence-based guidelines into policies, procedures, and protocols to guide nephrology nutrition practiceXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to bridge research to practice through journal clubs, interdisciplinary discussions, and practice-based research networks (eg, Academy’s NRN,
      NRN = Academy of Nutrition and Dietetics Nutrition Research Network.
      EAL, RPG,
      RPG = Academy of Nutrition and Dietetics Renal Dietitians Practice Group.
      NKF-CRN,
      NKF-CRN = National Kidney Foundation Council on Renal Nutrition.
      local renal networks)
      XXX
      4.4BParticipates in practice-based research networks (eg, Academy NRN or EAL workgroup) and the development or implementation of practice-based researchXX
      4.4CFunctions as a co-author or co-investigator of research and position or practice papersXX
      4.4DServes as primary or senior investigator, advisor, or preceptor on research teams that examine relationships between nutrition and kidney diseaseX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AIdentifies research questions and participates in studies related to nephrology nutrition care and servicesXXX
      4.5BCollaborates with interdisciplinary or interorganization teams to perform and disseminate nephrology nutrition researchXX
      4.5CLeads interdisciplinary or interorganization collaborative research activities and integration of research data into publications and presentations related to nephrology nutritionX
      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 Indicators
      The “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
      5.1A1Demonstrates ability to review and apply evidence-based guidelines when communicating and disseminating informationXX
      5.1A2Demonstrates ability to convey clinically complex concepts to other health care practitioners, patients/clients, and the publicX
      5.1BIdentifies and reviews relevant nephrology-related nutrition and education publications, resources, and public health trends (eg, prevalence, prevention, and treatment) and applies to practiceXXX
      5.1CInterprets regulatory, accreditation, and reimbursement programs and standards for organizations and providers that are specific to nephrology care and education (eg, CMS, accreditation organization, Medicare MNT coverage guidelines); seeks assistance if neededXXX
      5.1DContributes to and advocates for the advancement of the body of knowledge for the profession (eg, research, presentations, publications, patient/client education)XX
      5.1EServes as an expert resource/opinion leader for colleagues, other health care practitioners, the community, and outside agencies related to nephrology 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
      5.2A1Determines the most appropriate information and best educational method to present/disseminate information based on level of understanding of the individual or target audience (eg, family, care providers, professional colleagues, administrators, or the community)XXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Identifies and uses web-based/electronic nephrology tools/resources (eg, lifestyle apps) and electronic health records, and telehealth platforms within worksite as appropriateXXX
      5.2B2Develops and updates web-based/electronic nephrology nutrition tools/resources (eg, lifestyle apps, blogs)XX
      5.2B3Seeks opportunities to contribute expertise to large-scale bioinformatics/medical informatics projects as applicableX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AIntegrates and applies current and emerging scientific knowledge of nephrology nutrition, when considering an individual’s health status, behavior barriers, communication skills, and interdisciplinary team involvement; seeks collaborative guidance if neededXX
      5.3BLeads the integration of current and emerging knowledge from clinical research findings and consultation, in the management and resolution of complex problems in nephrologyX
      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
      5.4A1Contributes to the educational and professional development of credentialed nutrition and dietetics practitioners, interns, students, and other health care practitioners through formal and informal teaching, preceptorship, and mentorshipXX
      5.4A2Builds and maintains collaboration between researchers, educators, and decision makers to facilitate effective knowledge transfer for health practitioners’ education programsX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Recommends current, evidence-based CKD and nephrology nutrition educational resourcesXXX
      5.4B2Connects patients/clients/advocates and support networks with programs/services within the patients’/clients’ ethnic/cultural community to positively influence health-related decision making and outcomesXXX
      5.4B3Contributes to development of patient/client education materials/classesXXX
      5.4B4Leads individuals and groups in efforts to identify and secure appropriate and available resources and services (eg, senior meal programs, credible websites)XX
      5.4B5Develops, manages, and refines processes to identify, track, and monitor patient/client population’s use of specific ethnic/culture community resources, and collaborates as appropriateX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy and numeracy levels, need for translation of written materials or a translator, communication skills, and learning, hearing or vision disabilities)XXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interdisciplinary health care and management team, organization, and communityXXX
      5.5AContributes formally and informally to the interdisciplinary team (eg, shares relevant articles, investigates queries, serves as nutrition subject matter expert)XXX
      5.5BCommunicates with members of the interdisciplinary team and other providers to promote the use of evidence-based guidelines/practices and the EAL to integrate nutrition care in the management of CKDXXX
      5.5CParticipates in interdisciplinary collaboration(s) promoting the use of evidence-based guidelines/practices that integrate nutrition care and RDNs in CKD management to local, state, regional, and national professional organizationsXX
      5.5DPromotes the specialized knowledge and skills of the nephrology RDN with the CSR or other credentials to the interdisciplinary teamXX
      5.5ELeads interdisciplinary collaborations at an organization levelX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents nephrology nutrition guidelines and research at the local level (eg, community groups, interdisciplinary team, colleagues)XXX
      5.6BServes in a leadership role for local and national organizations, publications (ie, editor or editorial advisory board), program planning committees, or within business/industry-related programs/advisory boardsXX
      5.6CPresents evidence-based nephrology nutrition research, guidelines, and information at professional meetings and conferences (eg, local, regional, national, or international)XX
      5.6DDirects collation of research data into publications (eg, systematic reviews, position or practice papers, review articles) and presentationsX
      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 nonprofit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AServes as a nephrology nutrition resource as an active member of local or state organizations, coalitions, or advisory boardsXXX
      5.7BPursues leadership development opportunities as a subject matter expert on local, regional, and national nephrology-related organizations, coalitions, or advisory boardsXX
      5.7CContributes nutrition-related expertise as a collaborator in national projects and professional organizations (eg, NKF, RPG, KDOQI, KDIGO, AKF, AAKP,
      AAKP = American Association of Kidney Patients.
      ANNA,
      ANNA = American Nephrology Nurses Association.
      NQF, CMS Technical Expert Panel)
      X
      5.7DIdentifies new opportunities for leadership and cross-discipline dialogue to promote nutrition and dietetics practice in a broader contextX
      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, and natural and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “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 nephrology nutrition programs and services (eg, staffing, marketing, budgeting, information management system/tools, billing when applicable)XXX
      6.1BRecognizes and uses resources (eg, education materials, training tools, staff time) effectively in the provision of nephrology nutrition services to achieve desired outcomesXXX
      6.1CManages effective delivery of nephrology programs and services (eg, budget, staffing, billing processes when applicable, program administration, education programs, materials development, and supplies)XX
      6.1DDirects or manages design and delivery of nephrology nutrition 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
      6.2BParticipates in collecting and analyzing patient/client population and outcomes data, program resource/service participation, and expense data to evaluate and adjust programs and servicesXXX
      6.2CLeads and participates in data collection regarding the population served, services provided, and outcomes (eg, demographic characteristics, staffing benchmarking, and payment/revenue)XX
      6.2DEvaluates the provision of nephrology nutrition care and services, including staffing levels (staff to patient ratio), payment/revenue data, and customer satisfaction/experience dataX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3ADemonstrates understanding of and adheres to regulatory and accreditation standards relevant to CKD and nephrology nutrition (eg, CMS Conditions for Coverage/Conditions of Participation, CMS MNT coverage guidelines, accreditation organization standards)XXX
      6.3BParticipates in evaluation, selection, and implementation of new products and services to ensure safe, optimal, and cost-effective delivery of nephrology nutrition care and servicesXXX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4AParticipates actively in QAPI, including collecting, documenting, and analyzing data relevant to resource use (eg, fiscal, personnel, services, materials, supplies) and recommends modificationsXXX
      6.4BUses data to modify resource management or delivery of services (eg, staffing, triage, nutrition supplements, education materials/tools) as necessary to achieve desired outcomesXX
      6.4CLeads interdisciplinary team in QAPI or in applying best practices to manage resourcesXX
      6.4DIntegrates quality measures and performance improvement processes into management of human and financial resources and information technologyX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AParticipates in developing or conducting regular surveys with patients/clients/advocates, interdisciplinary team members, community participants, and stakeholders to assess satisfaction; seeks assistance if neededXXX
      6.5BAnalyzes data related to program services and patient/client and stakeholder satisfaction; communicates results and recommendations for change(s)XX
      6.5CResolves internal and external problems that may affect the delivery of nephrology nutrition servicesXX
      6.5DImplements, monitors, and evaluates changes in nephrology nutrition care and service delivery based on data collection and analysisX
      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
      • Key performance indicators are identified and tracked in alignment with organization mission, vision, principles, and values
      A Interdisciplinary: The term interdisciplinary is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, nurse practitioners, pharmacists, psychologists, social workers, dialysis technicians, medical assistants, and occupational and physical therapists), depending on the needs of the patient/client/customer. Interdisciplinary could also mean interprofessional or multidisciplinary.
      B 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.
      C Medical staff: A medical staff is composed of doctors of medicine or osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.
      State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      D Nonphysician practitioner: A nonphysician 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 qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
      State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
      ,
      State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
      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 LTC 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.
      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#2016; 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). 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.
      Acronyms
      a MNT = medical nutrition therapy.
      b NIH = National Institutes of Health.
      c KDIGO = Kidney Disease: Improving Global Outcomes.
      d KDOQI = Kidney Disease Outcome Quality Initiative.
      e HP2020 = Healthy People 2020.
      f CMS = Centers for Medicare and Medicaid Services.
      g EAL = Academy of Nutrition and Dietetics Evidence Analysis Library.
      h MAT = measurement assessment tool.
      i 5-Star = CMS Five-Star Quality Rating System.
      j QIP = quality incentive program.
      k KDQOL = Kidney Disease Quality of Life Survey.
      l PHQ-2 = Patient Health Questionnaire-2 for mental health screening.
      m ISMP = Institute for Safe Medication Practices.
      n FDA = Food and Drug Administration.
      o USP = US Pharmacopeial Convention.
      p CKD = chronic kidney disease.
      q NCM = Academy of Nutrition and Dietetics Nutrition Care Manuals (adult and pediatric).
      r IDPN = intradialytic parenteral nutrition.
      s IPN = intraperitoneal nutrition.
      t ASPEN = American Society for Parenteral and Enteral Nutrition.
      u NKF = National Kidney Foundation.
      v ESRD = End Stage Renal Disease (increasingly being replaced by End Stage Kidney Disease [ESKD]).
      w AKF = American Kidney Fund.
      x USRDS = US Renal Data System.
      y DOPPS = Dialysis Outcomes and Practice Patterns Study.
      z SRTR = Scientific Registry of Transplant Recipients.
      aa NRN = Academy of Nutrition and Dietetics Nutrition Research Network.
      bb RPG = Academy of Nutrition and Dietetics Renal Dietitians Practice Group.
      cc NKF-CRN = National Kidney Foundation Council on Renal Nutrition.
      dd AAKP = American Association of Kidney Patients.
      ee ANNA = American Nephrology Nurses Association.

      References

        • Kent P.S.
        • McCarthy M.P.
        • Burrowes J.D.
        • et al.
        Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition.
        J Acad Nutr Diet. 2014; 114: 1448-1457
        • Kent P.S.
        • McCarthy M.P.
        • Burrowes J.D.
        • et al.
        Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Nephrology Nutrition.
        J Ren Nutr. 2014; 24: 275-285
        • 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.
        J Acad Nutr Diet. 2018; 118: 132-140
        • Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR)
        2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics.
        (Accessed December 4, 2020.)
        • Academy of Nutrition and Dietetics Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
        J Acad Nutr Diet. 2018; 118: 141-165
      1. Scope of Practice Decision Algorithm.
        (Academy of Nutrition and Dietetics. Accessed December 4, 2020.)
      2. State Operations Manual. Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders.
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020)
      3. State Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds.
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
      4. 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 27106-27157).
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
      5. 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#2016; 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). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
        (Accessed December 4, 2020.)
      6. 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.
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
        • 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.
        J Acad Nutr Diet. 2017; 117: 2003-2014
        • The Joint Commission
        Glossary.
        Comprehensive Accreditation Manual for Hospitals. Joint Commission Resources, Oak Brook, IL2019
        • Dreyfus H.L.
        • Dreyfus S.E.
        Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
        Free Press, New York, NY1986
      7. Definition of terms.
        (Academy of Nutrition and Dietetics. Accessed December 4, 2020.)
      8. Chronic kidney disease.
        (Academy of Nutrition and Dietetics Evidence Analysis Library. Accessed December 4, 2020.)
      9. Kidney Disease Outcomes Quality Initiative (KDOQI) History.
        (National Kidney Foundation. Accessed December 4, 2020.)
      10. National Kidney Foundation KDOQI Clinical Practice Guidelines in Children with CKD 2008 Update.
        Am J Kidney Dis. 2009; 53: S1-S124
      11. Kidney Disease Improving Global Outcomes (KDIGO) Guidelines. KDIGO.
        (Accessed December 4, 2020.)
        • Beto J.A.
        • Ramirez W.E.
        • Bansal V.K.
        Medical nutrition therapy in adults with chronic kidney disease: Integrating evidence and consensus into practice for the generalist registered dietitian nutritionist.
        J Acad Nutr Diet. 2014; 114: 1077-1087
      12. 42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for coverage for end-stage renal disease facilities; Final Rule.
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
        • Certified Clinical Transplant Dietitian (CCTD)
        NATCO.
        (Accessed December 4, 2020.)
        • Meyer D.
        • Mohan A.
        • Subev E.
        • Sarav M.
        • Sturgill D.
        Acute kidney injury incidence in hospitalized patients and implications for nutrition support.
        Nutr Clin Prac. 2020; 35: 987-1000
      13. Estimated glomerular filtration rate (eGFR).
        (National Kidney Foundation. Accessed December 4, 2020.)
      14. Estimating glomerular filtration rate.
        (NIH NIDDK. Accessed December 4, 2020.)
      15. ACR.
        (National Kidney Foundation. Accessed December 4, 2020.)
      16. Creatinine-based “bedside Schwartz” equation (2009).
        (National Kidney Foundation. Accessed December 4, 2020.)
      17. Public Law 92-603. GovInfo.
        (Accessed December 4, 2020.)
      18. State Operations Manual. Appendix H—Guidance to surveyors: End-stage renal disease facilities (Rev. 200, 02-21-20).
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
      19. Centers for Medicare and Medicaid Services. 42 CFR Parts 405, 482, 488, and 498 Medicare Program; Hospital conditions of participation: Requirements for approval and re-approval of transplant centers to perform organ transplants; Final rule.
        (US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
      20. State Operations Manual. Appendix X—Guidance to Surveyors: Organ Transplant Programs. (Rev 200, 02-21-20).
        (US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed December 4, 2020.)
      21. Decision memo for medical nutrition therapy benefit for diabetes and ESRD (CAG-00097N).
        (Centers for Medicare and Medicaid. Accessed December 4, 2020.)
        • Kramer H.
        • Jimenez E.Y.
        • Brommage D.
        • et al.
        Medical nutrition therapy for patients with non-dialysis-dependent chronic kidney disease: Barriers and solutions.
        J Acad Nutr Diet. 2018; 118: 1958-1965
        • Slinin Y.
        • Guo H.
        • Gilbertson D.T.
        • et al.
        Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.
        Am J Kidney Dis. 2011; 58: 583-590
        • Hart A.
        • Smith J.M.
        • Skeans M.A.
        • et al.
        OPTN/SRTR 2018 Annual data report: Kidney.
        Am J Transplant. 2020; 1: 20-130
      22. Chronic kidney disease initiative.
        (Centers for Disease Control and Prevention. Accessed December 4, 2020.)
      23. Jimenez EY, Kelley K, Brommage D, et al. Patient perspectives on access to medical nutrition therapy for nondialysis dependent chronic kidney disease. Poster presented at: National Kidney Foundation Spring Clinical Meetings 2020; March 2020.

      24. Acute kidney injury and ESRD facilities.
        (Centers for Medicare and Medicaid. Accessed December 4, 2020.)
        • Ikizler T.A.
        • Burrowes J.D.
        • Byham-Gray L.D.
        • et al.
        KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update.
        Am J Kidney Dis. 2020; 76: S1-S107
      25. EAL-KDOQI (CKD) Guideline (2020).
        (Academy of Nutrition and Dietetics Evidence Analysis Library. Accessed December 4, 2020.)
      26. Treat complications and comorbidities.
        (NIH NIDDK. Accessed December 4, 2020.)
        • Silverstein D.M.
        Growth and nutrition in pediatric chronic kidney disease.
        Front Pediatr. 2018; 6: 205
        • Bhambri A.
        • Del Rosso J.Q.
        Calciphylaxis: A review.
        J Clin Aesthet Dermatol. 2008; 1: 38-41
        • Blair D.
        • Byham-Gray L.
        • Lewis E.
        • McCaffrey S.
        Prevalence of vitamin D [25(OH)D] deficiency and effects of supplementation with ergocalciferol (vitamin D2) in stage 5 chronic kidney disease patients.
        J Ren Nutr. 2008; 18 ([published correction appears in J Ren Nutr. 2009;19(2):195]): 375-382
        • Danovitch G.M.
        Handbook of Kidney Transplantation.
        6th ed. Wolters Kluwer, Philadelphia, PA2017
        • Weddle D.O.
        • Himburg S.P.
        • Collins N.
        • Lewis R.
        The professional development portfolio process: Setting goals for credentialing.
        J Am Diet Assoc. 2002; 102: 1439-1444
        • Worsfold L.
        • Grant B.L.
        • Barnhill C.
        The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
        J Acad Nutr Diet. 2015; 115: 978-984
        • 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.
        J Acad Nutr Diet. 2015; 115: 811-815
        • Chambers D.W.
        • Gilmore C.J.
        • Maillet J.O.
        • Mitchell B.E.
        Another look at competency-based education in dietetics.
        J Am Diet Assoc. 1996; 96: 614-617
      27. Advancing American kidney health.
        (U.S. Department of Health and Human Services ASPE. Accessed December 4, 2020.)
      28. Executive Order on advancing American kidney health.
        (White House. Accessed December 4, 2020.)
        • Moore L.W.
        • Kalantar-Zadeh K.
        Implementing the “Advancing American Kidney Health Initiative” by leveraging nutritional and dietary management of kidney patients.
        J Ren Nutr. 2019; 29: 357-360
      29. ESRD Treatment Choices (ETC) Model. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
        (Accessed December 4, 2020.)
      30. Launch of the Advancing American Kidney Health Initiative.
        (National Kidney Foundation. Accessed December 4, 2020.)
      31. Academy advocates for the profession in comments to HHS.
        (Academy of Nutrition and Dietetics. Accessed December 4, 2020.)
      32. KidneyX Innovation Accelerator.
        (KidneyX. Accessed December 4, 2020.)
      33. Telehealth.
        (Academy of Nutrition and Dietetics. Accessed December 4, 2020.)
        • Chen Y.T.
        • Shao S.C.
        • Hsu C.K.
        • et al.
        Incidence of acute kidney injury in COVID-19 infection: A systematic review and meta-analysis.
        Crit Care. 2020; 24: 346
        • Hirsch J.S.
        • Ng J.H.
        • Ross D.W.
        • et al.
        Acute kidney injury in patients hospitalized with COVID-19.
        Kidney Int. 2020; 98: 209-218
        • Kalantar-Zadeh K.
        • Moore L.W.
        Renal telenutrition for kidney health: Leveraging telehealth and telemedicine for nutritional assessment and dietary management of patients with kidney disorders.
        J Ren Nutr. 2020; 30: 471-474

      Biography

      R. C. Pace is a corporate director of nutrition services, Satellite Healthcare, San Jose, CA.
      J. Kirk is a dietitian, Solid Organ Transplantation, University of Rochester Medical Center, Rochester, NY.