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Nephrology leadership program 5 quality control and improvment in dialysis and nephrology august 2019

  1. Leadership & Management Quality in Nephrology Dr. Ala Sh. Ali Consultant Nephrologist and Transplant Physician Nephrology and Renal Transplantation Centre The Medical City Nephrology Leadership Program – Ministry of Health , Part 3 August, 2019
  2. What Quality means ? Noun The standard of something as measured against other things of a similar kind; the degree of excellence of something. Adjective Of good quality; excellent.
  3. Medical Perspectives “Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine, McGlynn, 1997 This means “doing the right thing at the right time in the right way for the right person – and having the best possible results.”
  4. Three broad categories of quality defects: • Underuse, whereby scientifically practices are not used as often as they should be; • Overuse, especially of imaging procedures and prescription of antibiotics; and • Misuse, when a proper procedure is not administered correctly (such as prescribing the wrong drug)
  5. We should have Measurable Aims • Safe: Overall mortality rates or the percentage of patients receiving safe care; • Effective: How well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each visit; • Efficient: Analysis of the costs of care by patient, provider, organization, and community; • Timely: Waits and delays in receiving care, service, or results; • Patient centered: Patient and family satisfaction; • Equitable: Differences in quality measures by race, gender, income, and other population-based demographic and socioeconomic factors.
  6. The Donabedian Model • Structure refers to the manner in which care is delivered, including facilities, equipment, and human resources. • Process refers to all of the interactions between patients and providers, including diagnoses, treatments, preventive care, and patient education. • Outcomes are all of the effects of health care on health status of patients and populations, including changes in health status, behavior, knowledge, satisfaction, and quality of life.
  7. Quality and Accountability • Quality Control (QC): ensuring products/services are made/delivered to high standards, often through inspection, monitoring, recording. • Quality Assurance (QA): ensuring the processes will produce high quality products/services, often through internal/external audits. • Quality Improvement (QI): continuous process of identifying problems, examining solutions, and regularly monitoring solutions for improvement. • Performance Improvement (PI): measuring output and modifying processes/procedures to increase output, efficiency, or effectiveness.
  8. Quality Assurance vs. Quality Control Quality Assurance Comprises the administrative and procedural activities implemented in a quality system so that requirements and goals for a product, service or activity will be fulfilled. Systematic measurement, comparison with a standard, monitoring of processes and an associated feedback loop that confers error prevention Quality Control Data-driven quality strategy used to improve processes. Focused on process output. It is the way of preventing mistakes and defects and avoiding problems when delivering products or services to customers.
  9. Quality Assessment and Performance Improvement (QAPI) The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The QAPI program must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors.
  10. Plan, Do, Study, Act(PDSA) cycles The Model for Improvement The model for improvement provides a framework for developing, testing and implementing changes leading to improvement. Using PDSA cycles enables you to test out changes on a small scale. Building on the learning from these test cycles in a structured way before wholesale implementation. This gives stakeholders the opportunity to see if the proposed change will succeed and is a powerful tool for learning from ideas that do and don’t work. This way, the process of change is safer and less disruptive for patients and staff.
  11. Goal Decide what you want to change. Set a percentage or absolute change target. Establish a timeline for completion Better to start small than to over-reach P What will you do? Who will do it? When will it be done? What are the expectations? What data will be collected? D Carry out the plan, Document observations, Collect the data S Analyze the data, Did the process work? Was it enough? Was the objective met? Is the new process realistic? Are the resources available to implement this new process? A Process worked: Implement the plan, Process did not work: Revise the plan or start over with a new plan
  12. Sequential PDSA cycles Simultaneous PDSA cycles
  13. Data Sources
  14. Quality Improvement Tools Check SheetFishbone diagram Control Chart Histogram Pareto Chart Plots Flow Chart
  15. Physician Dietitian Social worker Dialysis Nurse Patient INTERDISCIPLINARY TEAM INTERDISCIPLINARY CORE TEAM
  16. Responsibilities of the Dialysis Unit Director
  17. Quality Metrics in ESRD Himmelfarb J, Kliger AS. End-stage renal disease: measures of quality. Annu Rev Med2007; 58: 387–39
  18. ESRD quality incentive program (QIP) • To promote high-quality services in outpatient dialysis facilities treating patients with ESRD. • The first of its kind in Medicare, this program changes the way CMS pays for the treatment of patients with ESRD by linking a portion of payment directly to facilities' performance on quality of care measures. • These types of programs are known as "pay-for- performance" or "value-based purchasing" (VBP) programs. • The ESRD QIP will reduce payments to ESRD facilities that do not meet or exceed certain performance standards. The maximum payment reduction CMS can apply to any facility is two percent. This reduction will apply to all payments for services performed by the facility receiving the reduction during the applicable payment year (PY).
  19. Challenges of QIP Increasing quality requirements. Fear of change. Costs for EHRs. Success takes time.
  20. Quality Management
  21. Quality Control

Notas del editor

  1. In 2002, the Institute of Medicine published Crossing the Quality Chasm, an influential book that framed all future discussions of quality health care. Crossing came on the heels of the IOM publication To Err Is Human (2000) and a Journal of the American Medical Association report (1998) that warned of "serious and widespread quality problems...throughout American medicine."
  2. The Healthcare Quality Book (2nd edition), edited by Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom.    
  3. The sequential progression from structure to process to outcome has been described by some as too linear of a framework,[12] and consequently has a limited utility for recognizing how the three domains influence and interact with each other.[13] The model has also been criticized for failing to incorporate antecedent characteristics (e.g. patient characteristics, environmental factors) which are important precursors to evaluating quality care.[14] Coyle and Battles suggest that these factors are vital to fully understanding the true effectiveness of new strategies or modifications within the care process.[15] According to Coyle and Battles, patient factors include genetics, socio-demographics, health habits, beliefs and attitudes, and preferences.[15] Environmental factors include the patients' cultural, social, political, personal, and physical characteristics, as well as factors related to the health profession itself.[15] Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Health Care, 15(suppl 1), i50–i58. Coyle, Y. M., & Battles, J. B. (1999). Using antecedents of medical care to develop valid quality of care measures. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, 11(1), 5-12. PMID 10411284 Agency for Healthcare Research and Quality. Medical Teamwork and Patient Safety: Chapter 4. Retrieved 28 January 2013.
  4. ephrologist’s tasks in patient care versus role as medical director in population health management in the dialysis cent
  5. 3rd International Conference on Quality of Life, November 2018