Quality Improvement

Background Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments. Methods Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care. Results We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited. Conclusions Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.


Using a Self-Assessment Tool to Evaluate PD Clinic Performance
Background: The foundational components of a PD program include predialysis education, timely start on dialysis, skilled PD catheter placement, dedicated nurses for patient training, protocol-driven practices, and continuity of care throughout the team. Data collection for the evaluation of center outcomes and practices forms the basis for continuous quality improvement (CQI) strategies. In countries where PD is the predominant therapy and the nurse to patient ratio is high, making optimal use of limited resources may help to improve clinical outcomes. This project evaluated the effectiveness of a PD Centre Self-Assessment tool to quantify and identify PD clinic key strengths and deficiencies compared to published clinical practice guidelines to support quality improvement programs.
Methods: A four-dimensional PD center self-assessment tool was developed as part of the introduction of Baxter's Renal Quality Program. The tool was completed by the multidisciplinary team at each center and enabled team assessment on physical space, PD program parameters, nursing skills, and utilization, as well as leadership support. Responses of the center assessments were reviewed and utilized to identify areas needing intervention, support and training.
Results: Four large PD centers in Mexico (250-600 patients/center) completed self-assessments as part of the pilot program. These self-assessments identified 3 areas in which current practices were aligned with published recommendations: PD training curriculum, utilization of patient training materials, and Lead Nephrologist for PD Clinic. There were 5 areas in which practices could be improved: ongoing data collection, regular examination of clinical outcomes, lack of or inconsistent use of clinical protocols, proactive patient training programs, and having a Continuous Quality Improvement program in place.
Conclusions: Utilization of the PD Center Self-Assessment tool enabled PD clinical teams to compare current outcomes and practices to published PD guidelines and recommendations, providing a basis for prioritizing and identifying key activities, development and implementation of protocols in a quality improvement program. Improved center alignment to published recommendations may provide the basis for improving outcomes for PD patients.

Barriers to Peritoneal Dialysis Perceived by Nephrologists in a Renal Facilities Network in Colombia
Introduction: Despite accepted reasons to initiate RRT with peritoneal dialysis (PD), this option is underused worldwide. The PD take-on rate in our renal facilities network has been decreasing since 2011; we undertook this study to evaluate perceptive barriers to choosing PD among nephrologists in order to identify actions for improvement.
Methods: In July 2014 nephrologists in our network were invited to answer a 26-item online self-administered anonymous questionnaire. Numeric, multiple choice, and 5-point Likert-type Scale questions were used.
Results: 93 nephrologists were invited to participate and 57 answered the survey: 80% were male; mean age was 44.9 yrs, with a mean of 12.9 yrs of practice. 71% responded that the ideal proportion of patients on PD was more than 50% and 37% currently had more than 50% in their units. Asked about reasons for this disparity, 74% opined that limited caregiver or social support was the important and most important reason related with patients and families. 72% said that the patients' and families' decision on choosing PD was more influenced by other patients' negative perception of the quality of PD. When given, 56% of nephrologists indicated that reinforcing their knowledge and abilities were important to improve their PD programs. 42% of respondents said they were not trained in catheter insertion, 45.6% wanted to be trained; 73% implanted catheters in up to 20% of their patients, and 51% referred to have primary success of implantation in 80% of the cases.
Conclusion: This survey showed differences between ideal and real proportion of PD patients in our facilities, main reasons for this disparity being related to patients: limited caregiver or social support and peer negative influence. Regarding catheter implantation, an important proportion of nephrologists referred were not trained and wanted to be; a high percentage do not place catheters in their facilities.

Peritoneal Dialysis Solution Shortage: A Short-Term Management Strategy
Background: Unanticipated peritoneal dialysis (PD) growth, as well as other unforeseen issues, has resulted in a PD solution shortage in the United States. While current levels of PD solution availability can support PD therapy for patients currently on PD, new PD initiation is being limited to patients with absolute medical need.
Study Design: Quality Improvement Report. Settings and Participants: Prevalent PD patients in 4 large dialysis clinics were screened to determine if they were being overdialyzed as defined by a weekly Kt/V (Kt/V w ) of over 2.5. Quality Improvement Plan: For patients with Kt/V w greater than 2.5, if feasible, a modified PD prescription was proposed. The goal was to minimize wastage of PD solutions and eliminate excess solution use in patients with Kt/V well above national and international guidelines.
Measures: All patients who had a total Kt/V w (PD and renal) measured in the prior 3 mos at each center were screened.
Result: 26% (102 of 393) of prevalent PD patients had a Kt/V w of greater than 2.5. Baseline average total daily PD volume prescribed was 9.8±2.7 L achieving a baseline average Kt/V w of 3.3±1.5. Baseline daily wastage of PD solution (solution unutilized and discarded after completion of therapy) was 1.7±1.1 L. Of the patients with a Kt/V w over 2.5, a modified prescription was deemed feasible in 78% (80 of 102). On average, 2.3±1.6 L of solution could be saved per patient (2.9±1.1 L for patients that had a change in prescription). If implemented, this could translate to elimination of enough PD solution wastage and optimized prescriptions to allow for one new peritoneal dialysis initiation every 3.5 prevalent PD patients that have a prescription modification and adequate supply for 7-8 new PD patients for every 100 prevalent PD patients.
Conclusions: While minimizing new elective patients onto PD has been proposed as one way to deal with the short-term solution shortage, patient-centric options are preferred. Our plan to eliminate PD solution waste at each clinic will allow for a higher number of patients to be started onto PD during this period of PD solution shortage without affecting overall PD solution supply. At the same time PD prescriptions can become more efficient, thereby minimizing unnecessary exposure of prevalent PD patients to higher volumes of dextrose. Ghaffari A., 1 Lakdawala R., 1 Jayavelu B., 2 McCleron M., 2 Fannin P., 2 Vietri C. Univ. of Southern California, 1 Los Angeles, CA, U.S.A.; Southwest Kidney Institute, 2 Tempe, AZ, U.S.A. PDI

Development of a Continuous Quality Improvement Program and Its Application in Mexican Hospitals
Background: Peritonitis continues to be a significant complication associated with peritoneal dialysis (PD), despite the improvement in PD techniques and the use of automated PD. It is a common cause of PD technique failure and hospitalization, which results in significant burden on society and impacts quality of life for patients. Continuous Quality Improvement (CQI) programs have been demonstrated to be effective in reducing peritonitis and improving mortality and technique survival, which helps to improve the value of PD for different stakeholders. The aim of this program is to develop a CQI process and pilot-test the process among 4 Mexico hospitals to quantify its effect in the reduction of peritonitis rates.
Methods: We developed our Renal Quality Program (RQP) focusing on peritonitis in 2013 by performing a detailed analysis of published literature with regard to peritonitis among PD patients, including root cause; prevention techniques; and clinical, economic, and patient quality of life impact The CQI progam was then pilot-tested among 4 hospitals with large number of PD patients (250-600 PD patients/center) in Mexico starting January 2014. Nephrologists and nurses from the 4 selected hospitals were invited to participate in the RQP training program, and then developed and implemented a customized CQI program in their respective hospitals.
Results: A CQI process, including self-assessment of the current situation using a new PD center self-assessment tool, fishbone analysis technique, infection management protocol, and Excel-based data collection, was developed. The CQI program was adapted to 4 hospitals in Mexico with each hospital having specific action items. All of them implemented infection management protocols following the CQI training. The preliminary results from hospital Toluca demonstrated a trend of decreasing peritonitis rate (from 1 episode every 26 mos to 1 episode every 32 mos) and reduced loss to HD across all 4 hospitals.
Conclusion: The CQI process developed in this study can be used as an effective tool for nephrologists and nurses to identify the root cause of peritonitis in their centers and develop corresponding appropriate action plans to address the problem. Further data need to be collected and analyzed to validate the effectiveness of the program.

Peritoneal Dialysis Unit Patient Experience Project
Background: Provincially the Ontario Renal Network provides leadership and strategic direction for delivery of renal services. One primary goal is to increase patient selecting independent dialysis as their modality. The Peritoneal Dialysis unit has experienced a 30% growth over the past year; with this growth the unit has seen an increasing number of patients exiting the program for various reasons including peritonitis and difficulty coping. For the unit to maintain this growth there must be a full understanding of the patient experience, what and how their experiences have impacted their outcome. With this information we are able to develop and improve processes already in place.
Goal: To sustain growth within the program, reduce preventable attrition, and improve the patient experience by redesigning processes based on the guiding principles from the Institute for Patient and Family Centered Care. The approach taken is to enhance patient and staff satisfaction within our peritoneal dialysis program at London Health Sciences Centre.
Approach: Experience-based design surveys were developed and distributed to patients at different stages of their care journey and all staff within the program. Qualitative interviews were conducted with patients who exited program. There has been active patient involvement throughout all aspects of the project (i.e., working groups, interviews, and steering committee). Statistical analysis will be performed with regard to underlying reasons for attrition. Process and value stream mapping were completed.
Outcomes: 1. Increase in care provider satisfaction. 2. Improvement in patient experience. 3. Active and consistent participation with direct and indirect stakeholders in the project. 4. 2% annual PD patient growth. Peritonitis rates of fewer than 1 infection in 30 patient-mos. 5. 1% reduction in attrition rate.
Application in Clinical Practice: New processes will inform program initiatives and development. Ensure adaptability by other programs at LHSC and external organizations at the regional and national levels. Scott S., Slattery J., Downing L. London Health Sciences Centre, London, ON, Canada.

PD+HD Combined Therapy Improves Health-Related QOL in PD Patients
Background: Because the effectiveness of PD+HD combined therapy in solute clearance and fluid management has been recognized, PD+HD combined therapy is widely accepted in Japanese CAPD patients. But only a few reports had examined whether PD+HD combined therapy improves health-related quality of life (HRQOL) in uremic PD patients.
Methods: PD+HD combined therapy consists of 5 days of CAPD and 1 HD session per wk. A 4-hr HD session is performed with a high-flux membrane. HD day and the next day, patients are released from bag exchange of CAPD. We prospectively assessed clinical parameters and HRQOL by using the Short Form Health Survey, Version 2 (SF-36) and the Kidney Disease Quality of Life Instrument-Short Form (KDQOL-SF) before and 1 yr after initiation of PD+HD combined therapy in 10 Japanese PD patients who could not achieve adequate solute clearance or fluid volume control.
Conclusions: By starting the PD+HD combined therapy, fluid volume management and uremic symptoms improve, better HRQOL can be obtained.