Implementation strategies

Background to our implementation strategy

Our implementation projects were realized by using the “breakthrough” methodology, developed by the Institute for Healthcare Improvement (

While using  this methodology we brought together a number of teams from hospitals who were seeking improvement in the screening and treatment of malnutrition.  We started with 6 hospitals in a pilot project and then expanded our project to 54 hospitals all over the Netherlands.

Each team typically sent three of its members to attend a kick-off meeting. From that point on, project leaders and additional members worked on improvements within their local organizations. The project leaders were supported by the Dutch Malnutrition Steering Group through Project Leader Workshops (2 or 3 per year) and continuous online support. After 1-1.5 years we organized a closing conference where hospitals could present their achievements and exchange ideas.

Key features of the breakthrough methodology

    • Use the model for improvement: set aims, establish measures, select changes
    • Create teams with enough authority in the organization to institute a change. Make sure that the team includes members familiar with all the different parts of the process: managers and administrators as well as those who work in the process itself including physicians, nurses, dietitians, cooks and diet aides. It is essential to get the board of the institution to sign a contract to support the implementation project and the team. Tasks then have to be allocated between members of the team. Click here for an example of a multidisciplinary project team and agenda for action. 
    • Measure the improvements during the implementation project, we used a system of process evaluations. We defined 6 measurements that had to be made at the following times
    • after the start of the implementation project
    • 2 weeks later
    • 6 weeks later
    • 3 months later
    • subsequently every 6 months
  • Provide the teams with downloadable tools that can be used immediately. These can include tools for analyzing the process, gathering the data, working effectively in groups, documentation material for patients or other team members, powerpoint presentations, information material

Political awareness

Political endorsement

To get ‘malnutrition’ on the political agendas, we used a stepwise approach.

Our first steps aimed to create awareness. Some of our activities are listed below:

  • We meet with (representatives of) our Minister of Health to create awareness of the extent and the additional costs of malnutrition
  • We provide annual prevalence data about malnutrition using the annual measurement of care problems
  • We get involved with more extensive quality improvement programmes; this appears to be the most effective way to get malnutrition on the different agendas
  • We use the support of a professional lobbying company to update us about new political themes and to help us to get access to the right people in the political world
  • We organise ‘Malnutrition Lunches’ with representatives of political parties to get wide political support
  • We organise press conferences to present malnutrition prevalence data for all health care settings
  • We organise visits to allow  politicians to meet staff in health care institutions where they can then start to understand  the real severity of disease-related malnutrition

Support and funding 

To get our practical projects supported and funded, we used the following strategies

  • we showed that easy solutions for the treatment of malnutrition are available
  • we made sure that all our project plans were aimed at implementation rather than research.
  • we  worked with, for example, government and health insurance companies to arrange easier access to nutritional supplements in the community
  • we used  practising healthcare professionals to develop our toolkits and materials thereby  enhancing implementation
  • our multidiscplinary Dutch Malnutrition Steering Committee is easily accessible and responsive, and, therefore, is always available to support or react to new developments

Recognition of the problem of disease related malnutrition by the EU

In 2009, representatives of health ministries from the EU’s Member States; the Czech Presidency of the EU; medical experts; health care officials; representatives of health insurance groups; ESPEN (the European Society for Clinical Nutrition and Metabolism); and ENHA (the European Nutrition for Health Alliance) reached the unanimous conclusion that malnutrition, including disease-related malnutrition, is an urgent public health and health care problem in Europe. Appropriate actions need to be taken to prevent malnutrition from continuing to compromise the quality of life of patients, to cause unnecessary morbidity and mortality and to undermine the effectiveness of our health care systems across Europe.

Malnutrition as important as obesity

The Dutch Ministry of Health has identified that malnutrition is as important a national problem as obesity. As a result the Ministry has made screening for malnutrition mandatory in all health care settings in the Netherlands. Dutch health care institutions and home care organisations must, therefore, take an active role in tackling malnutrition. The Dutch Ministry of Health has also funded the majority of the DMG malnutrition implementation projects in hospitals, nursing homes and home care.