QAPI PowerPoint presentation - ESRD Network of New England

Peggy Lynch, RN1

What is QualityAssessment &PerformanceImprovement?• It is the team continually examining the overall care given in the dialysis clinic andalways seeking ways to improve• It is an ongoing evaluation of operatingsystems & clinical process rather thanindividual problems• It is data driven2

Is QAPI different than CQI?Not really:• Both are data driven• Both focus on continual improvement in patient’sclinical outcomes• Both help identify if patient safety issues• Both focus on reducing errors• Both encourages the dialysis i clinic i to evaluateoperating process & systems instead of fixing oneproblem at a time3

Effective QAPIIs an ongoing program that achieves……Measurable improvements in health outcomesExamples:1. Reduction in medication errors2. Reduction in patient falls3. Increase in AV Fistula Rates4. Increase in number of patients with hgb 11‐12g/dL5. Improvement in staff retention6. Rd Reduction in skipped or shortened treatments4

Why Data Driven?• If system processes & clinical outcomes are notroutinely examined, tracked & trended thenproblem areas may not be identified• Aggregate data measures performance bothclinically & operationally• Ongoing g data collection o will depict ifimprovements are sustained5

Establish Goals for CPMs• Adequacy• Nutrition• Bone Disease• Anemia• Vascular Access• Medical Errors• Reuse• Pt. Satisfaction• Infection Control• KT/V, URR• Albumin levels• PTH, CA+, PO4• HGB, Ferritin• Decrease Catheters• Decrease specific errors• < adverse outcomes• Increase survey scores• vaccinationsi6

Developing Your QAPI• Write a clear statement of the purpose of theimprovement• Include numeric goals• Focus on issues that are important to your dialysisclinic – prioritize, how it impacts patient care• Include an estimated time frame for goal attainment7

QAPI : Team• Interdisciplinary approach• Health care team is multi‐faceted• Each discipline part of processes• Each discipline impacts each other• Each team member contributes• Each team member is responsible8

Implementing a QAPI• Collected data may identify problem areas• The Medical Director & health care team utilizesroot cause analysis to identify possible solutions• Implementation of possible solutions• Data collected post solution implementation toexamine effectiveness of solution put in place• Continue data collection to see if improvement issustained9

QAPI : Evaluation• Evaluate processes of care• Are we doing what we want to do?• Are practice guidelines followed?• Do protocols need to be re‐evaluated?• Is staff & patient education effective?10

What is Quality?Quality is a never‐ending cycleof continuous improvement.-Deming11

12Quality Alphabet SoupQATQM PIPDSACQIPDCAIOPQIRCQI

Model for ImprovementThe Improvement Guide. Langley, Nolan et al. 13

What are we trying to accomplish?• An aim is a clear statement t t of:• Intended improvement• How it is to be measureded• What is the time frame• Use an aim statement t t to:• Stay focused• Communicate expectations• Define success14

Multiple tests of change orRapid idCycles achieve goalWhat arewe tryingto accomplishHow will we knowthat a change is animprovement?A PS DWhat changes canwe make that willresult in improvement?A PS DA PS DWhat changes canwe make that willresult in improvement?A PS DWhat changes canwe make that willresult in improvement?What changes canwe make that willresult in improvement?15

Following o the PDSA Roadmapap• Plan• Do• Study y( (Check)• ActACTSTUDYPLANDO16

ActPlanP‐D‐S‐A‐CYCLE• PLAN: 1. IDENTIFY THE PROBLEM2. ANALYZE THE PROBLEM• DO: 3. DEVELOP SOLUTIONS4. IMPLEMENT SOLUTIONSStudyDo• STUDY: 5. EVALUATE RESULTS (if goal achieved go to step 6 ,if not go back to step 1• ACT: 6. STANDARDIZE SOLUTIONS7. MONITOR FOR CONTINUED IMPROVEMENT17

Immediate Correction RequiredExamples of serious health & safety issues:• Unsafe water or dialysate• Defective clinical equipment• Unsafe reprocessing of dialyzers• Epidemiological risks• Insufficient number of competent staff toperform scheduled treatments18

Some Conceptual Tools To Use•PDSA/Rapid Cycle•Flow Chart Diagram•Cause & Effect Diagram•Root Cause Analysis19

PDSA/RAPID CYCLEASSESSMENTPrioritizationEvaluation/ReportingCath.DataInfectionreviewrate on theClinical Outcome rise? ImprovedBrainstorm for/repeat cause &cycle solutionsPlanningImplementation20

Flow Chart DiagramReview of ReuseprogramReusesnumbersevaluatedReuse numbersWNLNoReview & identifysteps in the reuseprocess.Interview staff aboutprocess stepsYesContinue wiithprogramDothe steps equalthe process?NoEvaluatedifferencesYesRepeat evaluationof reuse numbers.Ischangeneeded?NoReview the processagain to identify thevariance.YesCreate cause &effect diagram toidentify contributingvariablesContinue to C&Ediagram21

Cause & Effect Diagram (Fishbone)PatientReproStaffDocumentation - Pt - Machine - DialyzerVolume - Pressure - Visual FailsVisual Inspection of EquipmentComplianceVascular AccessTime Delay ReproPost Tx. RinseUniform TechniquesParticipation in ProcessQualityPatientHeparin DosingBlood Sampling MethodCarePriming ProcedureDialyzer Size & HandlingRinse Back ProcedureReprocessing of DialyzerBlood Flow RateTime of TreatmentDialyzerKinetics22

Root Cause AnalysisClinic AVF Rate < Desired GoalFacility AVF Goal= 65%Fear of needlesAVF notprimarychoiceSurgeon BarriersPatientBarriersAVF GoalNot MetFacilityBarriersNephrologistsBarriersLate referral to surgeonNo VA coordinator23

Conclusion• Quality Assessment and Performance Improvement isthe responsibility of all dialysis clinics andpractitioners• An ongoing QAPI can make a positive difference in thequality of care we give, we all strive to do better• Both patients and staff will benefit from an effectiveQAPI program• The QAPI will help formalize what all practitionerswant; to continually improve our outcomes24

QUESTIONS???25