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

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.

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.”

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)

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.

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.

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.

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.

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.

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.

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

Sequential PDSA cycles Simultaneous PDSA cycles

Data Sources

Quality Improvement Tools
Check SheetFishbone diagram
Control Chart Histogram
Pareto Chart
Plots Flow Chart

Physician
Dietitian
Social
worker
Dialysis
Nurse
Patient
INTERDISCIPLINARY TEAM
INTERDISCIPLINARY CORE TEAM

Responsibilities of the Dialysis Unit Director

Quality Metrics in ESRD
Himmelfarb J, Kliger AS. End-stage renal disease: measures of quality. Annu Rev Med2007; 58: 387–39

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).

Challenges of QIP
Increasing quality requirements.
Fear of change.
Costs for EHRs.
Success takes time.

Quality Management

Quality
Control