CMS Gives Hospital Workers More Nutrition Autonomy

A revised federal rule allows registered dieticians who work in hospitals to practice at the top of their license. It's being welcomed by hospital associations as a way to save time and money.

Starting July 11, hospital registered dietitians will have the authority to write therapeutic diet orders for patients without necessarily getting prior approval from physicians.

The enhanced autonomy for RDs is part of sweeping rules changes that the Centers for Medicare & Medicaid Services believes can save about $3.4 billion over five years. The new rules respond to President Obama's 2011 Executive Order 13563 which encouraged the federal bureaucracy to reduce or revise antiquated and unnecessarily burdensome rules and regulations.

CMS says the rules changes for dietitians "save hospitals significant resources by permitting registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner. This frees up time for physicians and other practitioners to care for patients."

Provider stakeholders appear to be OK with this new rule. Understandably, the Academy of Nutrition and Dietetics is delighted. The new rule validates their professionalism and expands their scope, allowing them to practice at the top of their license.

"CMS's new rule will eliminate burdensome and superfluous regulations that are adding to our nation's healthcare costs," AND President Glenna McCollum said in prepared remarks. "Allowing registered dietitian nutritionists to independently order therapeutic diets and monitor and manage dietary plans for their hospital patients will save the country hundreds of millions of dollars and also help hospitals provide better multidisciplinary care."

"The Academy and our members could not agree more with CMS's conclusion that 'the addition of ordering privileges enhances the ability that RDs already have to provide timely, cost-effective and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.'" (For an exhaustive review of the new rule, check out AND's FAQ page.)

It appears that the American Medical Association is comfortable with the new rule, even though it nips at direct physician oversight. The AMA responded to my email query with this: "The AMA encourages physician-led healthcare teams where physicians and other health clinicians work together in the best interest of their patients. In this particular case, clear communication between members of the team is necessary as there are instances where patients require clinically appropriate dietary restrictions and the patient's physician has the most knowledge about the planned course of care."

The American Hospital Association is comfortable with the idea, too.

"We are happy with this in line with the general philosophy that we have which is that healthcare professionals ought to be allowed to practice at the top of their license or skill set," says Nancy Foster, AHA's vice president for quality and patient safety policy. "This allows dietitians to use their expertise to recommend and identify the right food regimen for our patients."

"The way CMS has implemented this, of course, means that in each individual organization the medical staff will have to review their criteria for how practitioners are privileged and credentialed to do any service they provide to patients."

In other words, this is not a passive rule change. Each hospital that choses to grant autonomy to its RDs must act to create new procedures to ensure that physicians and other clinicians and dietitians continue to communicate properly about patient nutrition.

"We think this creates the opportunity to provide better care, but it does require that coordination that wasn't required before," Foster says.

The rule is permissive, which means that each hospital can decide whether or not to grant these new privileges to their dietitians. "If a hospital is uncomfortable with that, or that physicians feel strongly that that is not the right way to go, one could chose to not implement the policy because it's up to the medical staff," Foster says.

She says AHA isn't recommending a specific course of action for the new rule because "that is not our area of expertise."

"We will look for guidance from others or best practices as organizations begin to implement this and share those with our hospitals. Many of our hospitals now belong to a patient safety organization that may help them as well with how to keep patients safe as you are making this transition in policy. We would promote those ideas."

CMS should be applauded for making these rules changes. Expanding the authority of RDs passes the common sense test. So too does the permissive nature of this rule change. This is not a mandate because some hospitals might not be in a position to implement this for any number of reasons. Each hospital clinical leadership team should be free to carry out the rules change at a pace that is appropriate with their circumstances.

Because the rule saves time and money, two precious commodities in healthcare, most hospitals will jump on the chance to implement it as soon as possible.