Continuous quality improvement in nephrology: a systematic review

Optimizing use of an electronic medical record system for quality improvement initiatives in hemodialysis: Review of a single center experience

INTRODUCTION

The complexity of managing patients with end-stage kidney disease on hemodialysis underscores the importance of implementing quality improvement (QI) initiatives to enhance patient safety and prioritize patient-centered care. To address this, we established a QI committee at our tertiary academic center focusing on evidence-based practices, patient-centered approaches, and cost efficiency. To facilitate the seamless implementation of QI initiatives, we leveraged the capabilities of our electronic medical record (EMR) system.

METHODS

This review details effective strategies for optimizing use of an EMR system to successfully implement QI efforts. Drawing from our experience, we provide detailed descriptions and practical insights that can be applied to other EMRs.

FINDINGS

The creation of a secure and accessible dashboard, offering real-time data on quality metrics, stands out as the most notable feature. This dashboard operates through an algorithm that merges data from both our dialysis and hospital EMR systems. Its primary objectives are to streamline the identification of high-priority patients, enhance team communication, and facilitate tracking of quality indicators. Additionally, we integrated clinical pathways, checklists, and standardized protocols into the renal EMR to ensure smooth implementation of QI interventions. Notable examples of these interventions include an incremental hemodialysis protocol, a new hemodialysis start checklist, vaccination care plans, and personalized kidney transplant workups. Programmed electronic automatic reminders have proven invaluable in ensuring timely follow-ups of assigned tasks. The EMR has also contributed to medication optimization and deprescribing by generating patient lists based on specific medication classes. Finally, the EMR's capability to swiftly generate lists of patients with specific features has significantly facilitated targeted QI interventions.

CONCLUSIONS

Leveraging the capabilities of an EMR system can be crucial for enhancing care of hemodialysis patients and implementing effective QI initiatives.

Patient Education for CKD and Decision Support in Primary Care: Findings From the EPIK Pilot Study

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) affects millions of people in the United States, yet effective interventions to address gaps in patient knowledge and engagement are not well-established. We developed and pilot tested a brief educational decision aid for patients with CKD who are being treated in primary care settings.

STUDY DESIGN

Pilot quality improvement (QI) study of a decision aid intervention.

SETTING & PARTICIPANTS

The decision aid was introduced and used in 1 of 2 general internal medicine primary care clinics for adult patients with CKD.

EXPOSURE

An electronic medical record-based patient educational decision aid called the Encounter Decision Intervention (EDI) developed using QI methods and with input from patients and clinicians for use during primary care visits to address a CKD diagnosis and engage patients in their clinical management.

OUTCOME

Perceived and objective CKD knowledge, CKD-specific stress, and patient satisfaction measured in both primary care clinics as assessed using validated surveys.

ANALYTICAL APPROACH

Fisher exact tests, t tests, and Kruskal-Wallis tests were used to detect univariable associations of outcomes with use of the EDI across primary care clinics.

RESULTS

Seventy-four patients completed the study (37 in each clinic). There were no statistically significant differences in patient characteristics between the clinics. The group treated in the clinic that used the EDI had statistically significantly higher satisfaction with their clinicians, with clinician communication, and with their overall care. The patients reported high satisfaction with the EDI, and the clinicians reported favorable usability.

LIMITATIONS

A nonrandomized comparison, small sample size, and possible differences across practice settings.

CONCLUSIONS

A new integrated educational decision aid was successfully implemented in a primary care setting. Pilot testing suggested that the EDI was associated with higher patient satisfaction with their primary care provider, with their clinician's communication, and with their overall care.

PLAIN-LANGUAGE SUMMARY

Most patients who have chronic kidney disease (CKD) are not aware of their illness. Few studies have explored whether patient education can increase patients' knowledge about CKD or influence patients' satisfaction with the care or communication they receive from their physicians. This study tested whether a short CKD education intervention implemented by the patient's physician was associated with patients' greater awareness of their CKD as well as their satisfaction with care and communication. This pilot study found that a decision aid for patients with CKD was implementable in a primary care setting. Patients who received CKD education felt more satisfied with their care and communication with their physicians compared with patients who did not receive the education.

Decision-maker roles in healthcare quality improvement projects: a scoping review

OBJECTIVES

Evidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking. We conducted a scoping review to identify QI projects involving decision-makers published in the literature and to describe the roles decision-makers played.

METHODS

Following the Joanna Briggs Institute framework for scoping reviews, we systematically searched for all types of studies in English or French between 2002 and 2023 in: EMBASE, MEDLINE via PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. Criteria for inclusion consisted of literature describing health sector QI projects that involved local, regional or system-level decision-makers. Descriptive analysis was performed. Drawing on QI and participatory research literature, the research team developed an inductive data extraction grid to provide a portrait of QI project characteristics, decision-makers' contributions, and advantages and challenges associated with their involvement.

RESULTS

After screening and review, we retained 29 references. 18 references described multi-site projects and 11 were conducted in single sites. Local decision-makers' contributions were documented in 27 of the 29 references and regional decision-makers' contributions were documented in 12. Local decision-makers were more often active participants in QI processes, contributing toward planning, implementation, change management and capacity building. Regional decision-makers more often served as initiators and supporters of QI projects, contributing toward strategic planning, recruitment, delegation, coordination of local teams, as well as assessment and capacity building. Advantages of decision-maker involvement described in the retained references include mutual learning, frontline staff buy-in, accountability, resource allocation, effective leadership and improved implementation feasibility. Considerations regarding their involvement included time constraints, variable supervisory expertise, issues concerning centralised leadership, relationship strengthening among stakeholders, and strategic alignment of frontline staff and managerial priorities CONCLUSIONS: This scoping review provides important insights into the various roles played by decision-makers, the benefits and challenges associated with their involvement, and identifies opportunities for strengthening their engagement. The results of this review highlight the need for practical collaboration and communication strategies that foster partnership between frontline staff and decision-makers at all levels.

Quality Improvement in Stroke Rehabilitation: A Scoping Review

Background

Quality improvement interventions are used extensively in health care, aiming to improve delivery and promote best practice. The impact of quality improvement interventions implemented in stroke rehabilitation remains unclear.

Objective

The aim of this scoping review is to examine the different types of published quality improvement interventions in stroke rehabilitation and their impact on improving the quality of care.

Materials and Methods

A scoping review was performed in the PubMed, Embase and CINAHL databases. QI studies evaluating interventions for stroke rehabilitation patients that were published up to August 2020 were included. The review looked at the types of quality improvement interventions that have been evaluated as well as the improvements/impacts reported for quality improvement interventions for stroke patients in rehabilitation.

Results

We reviewed 1580 studies, twelve quality improvement interventions met inclusion criteria and were included in the current study. Six studies involved organizational change, three studies involved provider education and audit-feedback and three studies involved provider education. Of the twelve quality improvement interventions that have been included, >90% reported improvements (91.6%). In the majority of cases, improvements were noted through implementation of a myriad of interventions. Several facilitators and barriers were noted during implementation and contributed to success or failure of the intervention.

Conclusion

There is paucity of full-text peer-reviewed published research investigating quality improvement interventions for improving the quality of care in stroke rehabilitation. The current review offers value to healthcare providers in terms of key success factors, contextual factors, barriers and facilitators associated with improvements in stroke rehabilitation.

Leveraging digital transformation to empower clinical governance: enhancement in intermediate clinical endpoints and patients' survival after implementation of a continuous quality improvement program in a large dialysis network

BACKGROUND

Treatment of end-stage kidney disease patients is extremely challenging given the inter-connected functional derangements and comorbidities characterizing the disease. Continuous Quality Improvement (CQI) in healthcare is a structured clinical governance process helping physicians adhere to best clinical practices. The digitization of patient medical records and data warehousing technologies has standardized and enhanced the efficiency of the CQÍs evidence generation process. There is limited evidence that ameliorating intermediate outcomes would translate into better patient-centered outcomes. We sought to evaluate the relationship between Fresenius Medical Care (FME) medical patient review CQI (MPR-CQI) implementation and patients' survival in a large historical cohort study.

METHODS

We included all incident adult patients with 6 months survival on chronic dialysis registered in the EMEA region between 2011-2018. We compared medical Key Performance Indicator (KPI) target achievements and 2-year mortality for patients enrolled prior and after to MPR-CQI policy onset (Cohort A and Cohort B). We adopted a structural equation model where MPR-CQI policy was the exogenous explanatory variable, KPI target achievements the mediator variable, and survival was the outcome of interest.

RESULTS

4.270 patients (Cohort A: 2.397; Cohort B: 1.873) met the inclusion criteria. We observed an increase in KPI target achievements after MPR-CQI policy implementation. Mediation analysis demonstrated a significant reduction in mortality due to indirect effect of MPR-CQI implementation through improvement in KPI target achievement occurring in the post-implementation era (OR: 0.70; 95%CI: 0.65-0.76; p < 0.0001).

CONCLUSIONS

Our study suggests that MPR-CQI achieved by standardized clinical practice and periodical, structured, medical patient review may improve patients' survival through improvement in medical KPIs.

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

BACKGROUND

Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach.

METHODS

We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English.

RESULTS

Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities.

CONCLUSIONS

Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach.

TRIAL REGISTRATION

Protocol registered on PROSPERO (CRD42018088309).

Developing a classification system for haemoglobin management in patients with end-stage renal disease on haemodialysis: a secondary data analysis

BACKGROUND

Ongoing discussion on anaemia management and target haemoglobin (Hb) levels in patients on haemodialysis with erythropoietin treatment require a systematic approach in evaluating current practice. Aim of the present study was to develop a new classification system to easily monitor Hb trajectories and categorise patients on haemodialysis.

METHODS

Routine data from five dialysis centres in the USA collected between 2010 and 2016. Data were anonymised and only those from patients with fortnightly Hb values were included in the analysis. Entries on blood parameters and medication were standardised to achieve overall comparability. Data from each patient was grouped in periods of 120 days. Hb values above or below the target level of 10-12 g/dL were counted for each period. Periods were then assigned to Hb-classes according to the number of Hb values out of range per period: Hb-class I with 0-2, Hb-class II for 3-5 and Hb-class III for ≥6 values out of range.

RESULTS

Records from 3349 patients with fortnightly Hb values, information on haemodialysis data, laboratory parameters correlated to red blood cells and data on medication with erythropoiesis-stimulating agents (ESAs) were available. Patients were 64.4±15.9 years old; 55.0% were men. Statistical analysis revealed significant differences between Hb-classes in all of the examined parameters, except erythrocytes mean corpuscular volume and C reactive protein above the threshold, with more critical values in higher Hb-classes. The usage of ESAs showed a mean difference between Hb-class III and Hb-class I of 6.4 units/day and kilogram body weight in a 120-day period.

CONCLUSION

Our classification system allows an easily achievable overview of the patients' responsiveness and performance of Hb management. Integrated into a disease management programme or continuous quality improvement, the classification delivers an instant appraisal without complex statistical or mathematical processing.