Quality Assurance in Peritoneal Dialysis

HKARN 5th October 2008 Vanessa Foster General Manger FME Hong Kong

The Application of Rocket Science to Quality Management

NASA had conflicting goals of cost, schedule and safety" and unfortunately safety lost out". Major General John Barry
member of the Columbia Accident Investigation Board (CAIB).

Current issues in the Health Care setting High cost with decreasing reimbursement High mortality rates High hospitalization Unacceptable rehabilitation levels Variable quality of care and work environment Task orientation versus improvement focus

General Outcomes that may need improving

Clinical: Patient outcomes Administrative: job satisfaction, retention, professional development Financial: Financial performance of the organization Technical: Reuse, water quality, machine break down Regulatory: compliance with existing and pending regulations/ guidelines
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Examples of potential Clinical Quality Improvement projects include:

Delivery of prescribed dialysis Complications of therapy Blood pressure control Nutritional status Medication errors Adverse occurrences Patient compliance Mortality rates Lab errors, delays, omissions

Commonly used models in health care

The PDCA cycle (plan, do, check and act) FOCUS-PDCA (Find a process that needs to be improved; Organize a team of knowledgeable people; Clarify by studying the process, Understand the possible causes through data collection and analysis and Select a plan of action.
Follow the PDCA cycle

The Mantra of Quality Management

If you cannot / do not measure it You cannot manage it

Key Performance Indicators (KPIs)

Definition: A quantifiable entity that measures and evaluates a process or the result of a process deemed critical to achievement of a specific outcome

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Choosing relevant KPIs

Quantifiable
with reliability & accuracy

Sensitive
Abnormal value for KPI strongly associated with deviation from target

Specific
Abnormal value for KPI specific to target and not to other problems

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Frequency of KPI monitoring

As frequently as change / deviation from target likely to occur As frequently as is consistent with balance of risk of deviation and convenience of patient and clinical team Examples:
D/P creatinine tw.Kt/V / tw.CCr
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6 monthly 3 monthly

KPI may be interpreted specific to individual patient or to clinical cohort

Individual KPI value within prespecified target range
Examples: tw.Kt/V 1.8; Hb > 110 g/L; Albumin 35 g/L

Cohort Average and distribution of KPI values of all patients within prespecified target range
Examples: peritonitis rate > 24 months /episode (rate <0.5) tw.Kt/V average 1SD 1.8 80% of patients Hb > 110 g/L
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KPIs risk of infection

1. Hand hygiene staff & patients
Zero tolerance for non-adherence

2. Nasal carriage Staphylococci staff & patients

Zero rate

3. Exit site care

Demonstrated understanding and competence by patient every home/clinic visit Detailed exit site review and documentation by staff every home/clinic visit

4. Risk of peritoneal contamination

Demonstrated understanding and competence in bag exchange technique every home/clinic visit
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Peritonitis rate > KPI target

METHOD
understanding risk hand washing technique burn-out

PATIENT
staph carriage

general hygiene

exit site nutrition

KPI
connect system
storage conditions product quality education & training staph carriage competency general hygiene attitude Lab values

MATERIAL

STAFF
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Documenting and Tracking KPI

Control Chart

KPI value

INTERVENTION

Measurement frequency

e.g., individual patient body weight

Run chart
INTERVENTION

KPI value

e.g., units peritonitis rate: months per episode

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Measurement frequency

Process map - ALGORITM

SBP > 140 mmHg

YES

NO

Review in 2-3 months

Salt Intake < 8 g /day

YES

NO

Re-educate Dietetic assessment Record Assess & Manage volume status increase net daily UF Record

Assess & Manage volume status Consider antihypertensive Record

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Aids to QM numerous available

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