When working in policy, operationalizing change and functional leadership can be challenging. At the VA central office, a nutrition field advisory committee (NFAC) successfully leads the change from policy to practice. This model provides the benefits of field experience, implements change, and offers staff professional growth opportunities.

Nutrition and Food Services (NFS) in the Veterans Health Administration (VHA) provides veteran-centric nutrition care for our nation's veterans. This includes procurement, preparation, and delivery of safe and healthy food and tube feedings for veterans receiving care in the 152 VHA medical facilities throughout the nation and Puerto Rico. Additionally, NFS provides inpatient and outpatient medical nutrition therapy and nutrition education for all veterans who desire or require services. Registered dietitians, diet technicians, diet technicians-registered, and food service workers also participate in the education of dietetic interns as well as in research projects.

Nutrition care is delivered both through food service (i.e., the VA kitchen) and clinical (i.e., therapy) sections. This creates a dual identity within our service—business and clinical identities. The central leadership of NFS is housed in the Washington, D.C., VHA policy arm. However, many initiatives that are developed or regulated by policy must be implemented through facility (field) operations. To overcome the challenge, NFS uses a unique field advisory committee governance model to lead staff in the field and to communicate effectively.

Nutrition Field Advisory Subcommitee Structure

The VA NFS program office in Washington, D.C., oversees six field advisory subcommittees to govern the many aspects of both business acumen and clinical expertise in nutrition (see Figure 1):

• Business Subcommittee

• Subsistence Prime Vendor (SPV) Subcommittee

• Nutrition Marketing and Informatics (NMI) Subcommittee

• Quality and Performance Improvement (QPI)/Research Subcommittee

• Education and Professional Oversight Subcomittee

• Clinical Nutriton Subcommittee.

These subcommittees are geographically diverse, with membership applications solicited and selected from subject matter experts (SME) in the respective topic areas from all over the country. Subcommittees range in size from eight to 20 or more SMEs. Being chosen to serve on a subcommittee is a leadership and engagement opportunity open to all field-based staff.

These subcommittees each have a chair, and one or two co-chairs or assistant chairs for succession planning or coverage needs. These chairs make up the central NFAC, which serves as a sounding board and consensus group for strategic planning and operations implementation. The NFAC structure is aligned with all specialty care advisory committees' standardized approaches to governance.

NFAC Oversight

The NFAC is the central governance group in NFS, and is led by two individuals: the NFAC chair or manager, and the NFAC vice chair. The NFS national director in Washington has oversight. The chair, vice chair, national director, and NFS deputy national director divide oversight for the six subcommitees in NFAC.

They meet weekly to discuss issues brought forward by the subcommittee and make decisions based on recommendations from the subcommittees and by their own consensus. This process allows the committee chairs to have more freedom and time in their work, and allows central leadership to make decisions balanced between field recommendations and central office initiatives or external stakeholders.

NFAC Project Dashboard

Once a month, these leaders meet with the NFAC subcommittee chairs to discuss NFS programs. Each month, one or two subcommittees present their current progress. As each subcommittee has a diversity of projects and some 20 SMEs, they created a NFAC dashboard in Microsoft Excel and posted it on a Sharepoint site. The dashboard (spreadsheet) keeps all NFAC members current on projects in all six subcommittees, as well as on special projects by the national director and deputy national director.

This dashboard has tabs for each subcommittee, and connects each project with a VHA strategic plan goal, baseline measurement, goal measurement, point of contact, and timeline for completion. The dashboard is updated quarterly by the project leaders so that progress is always available to anyone needing information. All NFAC members can peruse the current projects of other subcommittees, which has promoted cross-collaboration among the groups.

For example, this year the deputy national director proposed a new research award. While the NMI subcommittee has jurisdiction over awards, the QPI/Research Subcommittee needed to be involved to create selection criteria for the award. In another example, the green environmental management workgroup of the business subcommittee is making significant strides in promoting farmers markets and sustainable food procurement, and educating facility NFS chiefs on the "greening" of NFS. This group needed expertise from business (administration of farmers markets), SPV (food procurement), and education and professional oversight subcommittees (training field-based staff).

This model of governance and dashboard facilitates improved communications, and ultimately, better services to veterans. Open communication and collaboration is encouraged at all levels to harness the expertise of staff to produce the highest quality, evidence-based product or service.

NFAC Challenges

Challenges with a subcommittee governance structure include

• continually identifying new staff to participate

• maintaining engagement throughout all levels of the subcommittee (for example, every link in the chain is vital)

• communicating about and organizing projects.

NFS uses national appeals to clinical managers in nutrition therapy or NFS chiefs in food service operations to identify new staff for subcommittees. The NFAC dashboard keeps projects on track, and uses visual communication so everyone can view all the projects for all subcommittees at once.

Maintaining engagement also is an ongoing consideration. Positions change or staff pursue new personal or professional goals or are assigned new priorities at the local level that compete or overtake NFAC project duties. However, NFS staff remain dedicated to the well-being and advancement of the veteran, and the VA. The NFAC subcommittee structure has been successful for more than 20 years in VA NFS.

NFAC Strengths and Benefits

Benefits of the NFAC Subcommittee governance structure include

• operationalization of policy changes or quality improvements

• targeted, yet free-flowing communication through specialized areas in NFS to see pertinent information in an area (i.e., clinical and food service)

• field expertise

• field representation and opportunities to participate in national leadership

• continual supply of new information, staff, and best practices that help shape both policy and operations.

Effective Leadership of a Multi-Level Department

The NFAC subcommittee governance structure is an effective way to lead a multi-level federal healthcare department, especially if the department has more than one categorical function. This model benefits the customer, staff, and leaders in many ways.

Using a project dashboard can improve internal communications across several subcommittees and boundary spanning communications in pursuit of coordinated fiscal year goals. Annual face-to-face meetings develop relationships and trust beyond what may be possible in the virtual world.

Initiatives that are developed or regulated by Veterans Affairs central office policy must be implemented throughout field operations. To overcome the challenge, NFS uses a unique governance model.