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  1. 1. JHQ • Web Exclusives • November/December 2007 W6-1 CONTENTS WEB ARTICLES W6-18 q&a: Tracy Sklar on Advancing Improvement in Acute Care Wayne E. Soo Hoo W6-3 Non-Nephrologist and Nephrologist Perspectives Tracy Sklar, MSc MBA, is the vice president for quality and service excellence in the care man- on Implementing a Chronic agement department of Catholic Healthcare West Kidney Disease Guideline (CHW). She has worked in the care management department for 6 years and at CHW for more than Meenal B. Patwardhan, David B. 18 years. Sklar is a highly effective process facilita- Matchar, William E. Haley, Gregory P. tor with strong analytical skills, and she has a well- Samsa documented record of leading successful clinical Providing care consistent with clinical practice improvement projects that have resulted in both guidelines for individuals with advanced chronic improved patient outcomes and cost savings. kidney disease (ACKD) is known to improve outcomes. Nephrologist and non-nephrologist perspectives regarding ACKD and preferences for tools to optimize patient management were iden- tified through focus group interviews. Six focus groups for nephrologists and non-nephrologists DEPARTMENTS from geographically distinct areas were conducted. Physicians discussed methods of identifying pa- tients, the referral process, overall management of W6-21 Media Reviews ACKD, the use of practice guidelines, and percep- tions regarding guideline implementation tools. Focus group insights were used to develop tools W6-24 Quality NETwork for implementing a guideline to optimize ACKD patient management. W6-26 Quality Products and Resources Vol. 29, No.6 www.nahq.org/journal/online/ © 2007 National Association for Healthcare Quality
  2. 2. JHQ • Web Exclusives • November/December 2007 W6-2 Web Exclusives Mission Vision Journal for Healthcare Quality is a professional forum Journal for Healthcare Quality is the first choice for that continuously advances healthcare quality prac- creative and scientific solutions in the pursuit of tice in diverse and changing environments. healthcare quality. Editor in Chief Editorial Board Review Panel for This Issue Luc R. Pelletier, MSN APRN BC Lecia A. Albright, CPHQ Christy L. Beaudin, PhD LCSW CPHQ CPHQ FNAHQ FAAN LARA Consulting, LLC FNAHQ Healthcare Consultant Spotsylvania, VA Los Angeles, CA San Diego, CA Christy L. Beaudin, PhD LCSW CPHQ Jean A. Grube, PhD MBA MSN FNAHQ Special Issue Editors Childrens Hospital of Los Angeles Madison, WI Jean A. Grube, PhD MBA MSN Los Angeles, CA Tracey Lynn King, MSN RN CPHQ Medical College of Wisconsin CCRN CPUR Madison, WI Sue Boisvert, MHSA RN Cape Coral, FL Parkview Adventist Medical Center Diane M. Peters, MS RN NHA Brunswick, ME Pathway Health Services White Bear Lake, MN Diane Brown, PhD RN CPHQ FNAHQ Kaiser Foundation Hospitals Research Editor Pittsburg, CA Robert J. Rosati, PhD Jacqueline Fowler Byers, PhD RN Visiting Nurse Service of New York CPHQ CNAA FAAN New York, NY University of Central Florida Orlando, FL Interviews Editor Steven Douglas Chinn, DPM MS CHE Susan V. White, PhD RN CPHQ CPHRM CPHQ FNAHQ VA Palo Alto Healthcare Systems Healthcare Consultant Palo Alto, CA Windermere, FL The Joint Commission Oakbrook Terrace, IL q&a Editor Joann Genovich-Richards, PhD MBA Deborah M. Flores, EdD MBA RN MSN RN Corpus Christi Medical Center Sharendipity Enterprises, Inc. Corpus Christi, TX Sterling Heights, MI Quality NETwork Editor Lenard L. Parisi, MA RN CPHQ FNAHQ Daniel H. van Leeuwen, MPH RN Metropolitan Jewish Health System CPHQ Brooklyn, NY St. Peter’s Hospital Kevin C. Park, MD CHCA Albany, NY Attest Health Care Advisors LLC Las Vegas, NV Media Editor Pamela K. Scarrow, CPHQ Jean A. Grube, PhD MBA MSN American College of Obstetricians Medical College of Wisconsin and Gynecologists Madison, WI Washington, DC Senior Managing Editor Wayne E. Soo Hoo, PhD MSN RN Barbara Hofmaier, MAT CPHQ Glenview, IL Mercy San Juan Medical Center Carmichael, CA Graphic Designer Sandra E. Ward, MA MS RN CPUR Eric Trisilla CPHQ Glenview, IL HIP Health Plan of New York New York, NY Editorial Assistant Meaghan Olson Glenview, IL NAHQ 2006–2007 Board of Directors Heidi Benson, MS RN CPHQ FNAHQ Carol Lee Hamilton, JD MPA RN CPHQ President FNAHQ Thomas M. Smith, MA RN CPHQ Member Services Director President-Elect Linda Scribner, BA CPHQ Anna Marie Butrie, MSN MPH CPHQ Professional Development Director FNAHQ Joan Boldrey, MEd MS RN CPHQ Immediate Past President Ex-Officio, HQCB Chair (2007) Sandra Grinder, MSN RN CPHQ Stacy Sochacki, MS Secretary-Treasurer Ex-Officio, Executive Director Journal for Healthcare Quality is an official publication of the National Association Quality. The association reserves the right to accept, reject, or alter all editorial Vol. 29, No. 6 for Healthcare Quality (NAHQ) and is a refereed journal. Journal articles express and advertising material submitted for publication. Advertising published in the www.nahq.org/journal/online/ the authors’ views only and are not necessarily the official policy of NAHQ or the journal does not imply endorsement of products and services. Members of the © 2007 National Association for editors of the journal. The Information for Authors is available at www.nahq.org/ National Association for Healthcare Quality receive a subscription to Journal for Healthcare Quality journal/resource/pubsauth.htm or from the editorial office of Journal for Healthcare Healthcare Quality as a benefit of membership.
  3. 3. JHQ • Web Exclusives • November/December 2007 W6-3 Non-Nephrologist and Nephrologist Perspectives on Implementing a Chronic Kidney Disease Guideline Meenal B. Patwardhan, David B. Matchar, William E. Haley, Gregory P. Samsa Chronic kidney disease (CKD) is a condition Abstract: Providing care consistent with clinical practice that involves gradual loss of kidney function guidelines for individuals with advanced chronic kidney dis- over time. The condition is divided into stages ease (ACKD) is known to improve outcomes. Nephrologist and of increasing severity, and the final stage is referred to as end-stage renal disease (ESRD), non-nephrologist perspectives regarding ACKD and preferenc- or advanced CKD (ACKD). ACKD, involving es for tools to optimize patient management were identified minimal kidney function, is a source of sig- through focus group interviews. Six focus groups for nephrol- nificant mortality and morbidity in the United ogists and non-nephrologists from geographically distinct States (McCrory et al., 2002; Pereira, 2002; Schoolwerth et al., 2006). areas were conducted. Physicians discussed methods of iden- The prevalent population of individu- tifying patients, the referral process, overall management of als with ACKD is projected to increase from ACKD, the use of practice guidelines, and perceptions regard- 325,000 in 2003 to 660,000 by 2010 (National ing guideline implementation tools. Focus group insights Kidney Disease Education Program [NKDEP], 2006), and the annual mortality rate for ACKD were used to develop tools for implementing a guideline to patients is approximately 20% (Schoolwerth et optimize ACKD patient management. al., 2006). Providing optimal care in the stage prior to ACKD, is known to improve outcomes even though a guideline for improving quality Key Words by slowing progression of the disease and by of care during ACKD that addresses all clinically reducing mortality and morbidity if the indi- chronic kidney disease relevant management areas has been developed vidual progresses to ACKD (Obrador et al., (Renal Physicians Association, 2002). focus groups 1999; Pereira, 2002; Schoolwerth et al.). It is well documented that mere creation and guideline implementation In order to optimize care of ACKD, early dissemination of practice guidelines is not suf- identification of the condition is essential ficient for practice improvement (McClellan, (National Kidney Foundation [NKF], 2002), but Knight, Karp, & Brown, 1997). To facilitate there is evidence that fewer than 20% of patients improvements in patient outcomes based on at risk for CKD are screened for the condition adherence to guidelines, a set of tools and strat- (NKDEP, 2006). Identification and management egies is needed. of ACKD patients occur in a range of settings: One systematic approach to develop- solely in a non-nephrologist (e.g., primary care ing guideline implementation tools is facili- provider, cardiologist, endocrinologist) practice, tated process improvement (FPI) (Matchar, solely in a nephrologist practice, or comanaged Patwardhan, Samsa, & Haley, 2006). FPI is between nephrology and non-nephrology prac- based on continuous quality improvement tices (NKF). Regardless of the setting, though, principles and involves (1) understanding the management of individuals with CKD is known process, (2) identifying process failures and to be suboptimal. Further, the problem of sub- root causes, (3) developing tools to attack root optimal management remains, despite the fact causes, and (4) establishing a tailoring strategy that initiating appropriate treatment makes a (so that physicians can select tools appropriate difference. Several studies have demonstrated for their practice situation). the impact of intervention on levels of hemoglo- FPI is well suited for quality improvement bin, malnutrition, permanent vascular access, in healthcare settings because it requires an and overall survival of individuals with CKD Journal for Healthcare Quality external expert team (rather than busy clini- Web Exclusive (Brenner et al., 2001; Nissenson et al., 2001; cians) to develop guideline implementation Vol. 29, No. 6, pp. W6-3–W6-17 www.nahq.org/journal/online/ Patwardhan, Samsa, Matchar, & Haley, 2007; tools. Following these principles, the research- © 2007 National Association for Stack, 2003). Suboptimal management exists ers involved in the current exercise used FPI Healthcare Quality
  4. 4. JHQ • Web Exclusives • November/December 2007 W6-4 to create a set of tools to overcome barriers to (an area of approximately 1,556 square miles) improvement in ACKD care. We used a focus- were invited to attend one of two in-person focus group interview technique that accomplished groups (one each for nephrologists and non- the first three FPI steps: (1) to understand nephrologists); all other physicians participated physician perspectives regarding the process in one of four telephone focus groups (two for of managing individuals with ACKD, (2) to rec- nephrologists and two for non-nephrologists). ognize why ACKD management is suboptimal, All six focus groups convened from February and (3) to develop tools that can effectively to July 2004. We used the same interview guide address the root causes of process failures in with each group. ACKD. The Institutional Review Board of Duke We used a convenience sample for our University approved our study. After obtain- focus groups and used informal methods to ing informed consent from all participants, interpret the focus-group results. These results a trained moderator led and audiotaped all provided us with valuable information regard- 90-minute focus groups using standard mod- ing physician perspectives on CKD manage- eration techniques (Giacomini & Cook, 2000). ment and guideline implementation tools. We Prior to each session, we provided partici- supplemented these focus-group results with pants with an evidence-based ACKD guide- a literature review and developed a set of tools line (Renal Physicians Association, 2002) and intended to improve the management of indi- a list of commonly used guideline imple- viduals with CKD through the implementation mentation tools (e.g., flow charts and patient of an ACKD guideline—Appropriate Preparation education material). Participants provided of the Patient for Renal Replacement Therapy demographic data regarding themselves and (Renal Physicians Association, 2002). The set of their practices. tools, their intent, and some details on the tools At the beginning of each group, confidential- are included in Table 1. ity of participants was discussed. The manner in which patients with ACKD were identified and Methods managed was explored. Participants described We divided physicians into two groups: neph- problems associated with the involvement of rologists and non-nephrologists (family prac- two physician specialties in CKD care and the titioners, internists, and endocrinologists). We referral process in general. The moderator then also chose to combine two focus-group tech- led the discussion toward the use of clinical niques for both physician groups: in-person practice guidelines in general and in the man- and telephone focus groups. In order to recruit agement of CKD and physician perceptions physicians, we used lists from two profes- regarding the ACKD guideline in particular. sional organizations: the American Medical Finally, the moderator initiated discussions Association (AMA) and the Renal Physicians of guideline implementation tools using the Association (RPA). list provided and encouraged participants to We randomly selected 100 physicians (pri- brainstorm about tools beyond that list. All mary care providers, cardiologists, and endocri- questions were open-ended. nologists) from the AMA list. We invited them The moderator reviewed and transcribed to participate in focus groups through a letter all the focus group audiotapes and provid- followed by a telephone call. Of the physicians ed a summary report. The audiotapes and who responded to our invitation, we included summary report were reviewed by a neph- the first 14 in our focus groups and reimbursed rologist, an internist, a statistician, and a them for their time. These physicians formed health services researcher. The reviewers ana- the non-nephrologist group. Using identical lyzed the data and subsequently discussed methods, we randomly selected 100 neph- the analysis among themselves. Because the rologists from the RPA list and invited them to objective of this exercise was to give input participate in the focus groups through a letter for the process of tool development, we did followed by a telephone call. We included the not use the expensive techniques of coding first 14 nephrologist respondents in our focus data with software. Our analytic approach groups and reimbursed them for their time. involved an informal, iterative process of Nephrologists and non-nephrologists prac- review and deliberation that led to meaning- ticing within the Triangle area of North Carolina ful themes pertaining to research questions
  5. 5. JHQ • Web Exclusives • November/December 2007 W6-5 Table 1. Tools Included in The Advanced Chronic Kidney Disease Management Toolkit, Their Intent, and the Available Formats (continued) Name of Tool and Intended User Intent of Tool Format of Tool Meta-Tool Serves as a directory of tools and pro- Two formats: “quick-start” vignettes for typical Physician practice intending to vides insight for tool selection and strat- practices, and an “insight” meta-tool based on the use advanced chronic kidney egies for tailoring to local circumstances characteristics of a practice environment disease (ACKD) toolkit Assessment Tool: Patient Assesses existing practice performance Step-wise instructions for assessing practice Identification performance Physician practice identifying ACKD patients Assessment Tool: Patient Assesses existing practice performance Step-wise instructions for assessing practice Management performance Physician practice managing ACKD patients Physician Education Material+ Promotes education by identifying 1. Microsoft PowerPoint presentation with notes Nephrologists patients, using glomerular filtration rate pages. Standard set (and some additional slides) (GFR), comanaging patients, and intro- 2. Executive summary of Renal Physicians ducing tools Association [RPA] Clinical Guideline Number 3 Awareness Letter* Raises awareness of chronic kidney Brief, one-page letter directed to the referring Nephrologist to colleagues disease (CKD), introduces concept of physician. Copy of the executive summary of RPA comanagement, and promotes education Clinical Guideline Number 3 could be attached to the letter. CKD Identification and Action Promotes identification of patients, Laminated card with CKD identification and Plan Card* appropriate timing of consult or referral action plan: classification of CKD stages and action Referring physicians, physician to nephrologist, and use of guidelines associated with each stage, keys to identification of extenders, nephrologists high-risk patients, indications of kidney damage, risk factors for progression, potential complica- tions, and concise guidelines CKD Identification and Action Promotes identification of patients, Poster for physician office with CKD identification Plan Poster appropriate timing of consult or referral and action plan (without guidelines) Referring physicians, physician to nephrologist, and use of guidelines extenders, nephrologists GFR [Glomerular Filtration Identifies CKD patients on the basis of Four formats: slide rule, Web sites for PC use, Rate] Calculator* GFR instead of serum creatinine downloads for Palm or hand-held PC devices, and Referring physicians, physician letter for laboratory extenders, nephrologists CKD Chart Flags and Stickers Flags medical records of patients with Stickers to place on outside of patient medical Referring physicians, physician ACKD record extenders, nephrologists Referring Physician Fax-Back Assures nephrologists obtain important One-page fax form for communication between Form* clinical data; allows referring physician nephrologist and referring physician. Can be Nephrologist to referring physi- to clarify the purpose of referral individualized by adding a practice fax header or cian, faxed back to nephrologist inserting a clinic stamp CKD Post-Consult Letter* Communicates comanagement plan to Three formats: one-page form clarifying respective Nephrologist to referring physician referring physician roles of nephrologist and referring physician, bul- leted list to remind nephrologist while drafting his or her own letter, and Web site with “consult letter template” Advanced CKD Patient Serves as a reminder, a standing order, One-page flow sheet that goes in ACKD patient Management Flow Sheet and as a data repository for use with charts. Shaded areas correspond to data required Physician managing ACKD evaluation tools for patient management for the Post-Implementation Evaluation Tool: patients Patient Management Advanced CKD Algorithms* Provides implementation guidelines at Algorithms (one page each) for anemia, Physicians and providers point of care hypertension, bone disease, nutrition, and lipids managing ACKD patients continued
  6. 6. JHQ • Web Exclusives • November/December 2007 W6-6 Table 1. Tools Included in The Advanced Chronic Kidney Disease Management Toolkit, Their Intent, and the Available Formats (continued) Name of Tool and Intended User Intent of Tool Format of Tool Nephrology CPT Codes* Provides nephrology current procedural Laminated pocket card Nephrologists and providers terminology reference codes and docu- managing ACKD patients mentation guidelines Supplemental Tools (Includes Helps provide dosage adjustments for 1. Reference for downloading eDrugsRenal (a free eDrugsRenal* and PDA patients with CKD and useful Web sites software program that recommends dosage adjust- Downloads for Tools*) for PDA programs ments) Referring physicians, physician 2. General information regarding downloading PDA extenders, nephrologists programs Patient Diary (Personal Health Serves as a patient education and Card with patient and provider name and a series Record) self-management tool, and a patient of kidney diagrams shaded to reflect the patient’s Patient reminder and patient-initiated physician degree of kidney function and CKD stage. Inside the reminder card is a flow sheet similar to the one in the patient chart. Also has the lay version of goals of care and recommendations from the RPA guideline CKD Class Resources* Provide resources for CKD classes and Three-page resource sheet for practices interested Practice and patient for patient education and self-manage- in starting their own formal ACKD classes or in ment prescribing existing classes. Includes resources for patient education and self-management Patient Education Resources* Serve as a resource for patient education Brief description of several patient education Patient and caregiver tools resources with contact information. Formatted as a patient handout Venipuncture Reminder Card Remind patient and healthcare provid- Instruction card with removable wallet card Patient ers to protect arm veins in nondominant arm for future vascular access Vascular Access Passport Provide patient with information on Multipage, passport-size booklet in a protective Patient catheter and vascular access placements plastic sleeve Post-Implementation Evaluation Evaluate the impact of tools on patient Step-wise instructions for performing the evaluation Tool: Patient Identification identification and nephrology consult or Practice identifying ACKD referral patients Post-Implementation Evaluation Evaluate impact of tools on patient Step-wise instructions for performing the evaluation Tool: Patient Management management using the ACKD management flow sheet (used as a Practice managing ACKD management tool) patients Note.The term nephrologist includes all physicians who manage ACKD patients. Tools that are underlined are those that require reconfiguration of clinic processes. *These tools are suitable for downloading into a Palm or hand-held PC device (refer to Palm downloads at www.renalmd.org). +This presentation may be made using a Palm or hand-held PC device with add-on software. (Mays & Pope, 1995). Figure 1 presents the although the depth of discussions was greater discussion guide used for the focus groups, in the in-person focus groups: and Table 2 presents some of the questions. • ACKD patients are not identified early. • The referral process is disorganized. Results • Ongoing patient management is unsatis- Twenty non-nephrologists and 38 nephrologists factory. responded to our invitation to participate in a • Clinical practice guidelines are used to a focus group (overall response rate was 29%). We varying extent. included the first 14 non-nephrologist respon- • Some tools could help physicians imple- dents and the first 14 nephrologist respondents ment practice guidelines. in our focus groups. Table 3 describes features The extent of agreement among physicians of the participating physicians and their prac- regarding any given idea is described here in tices. Identical themes emerged in the two qualitative terms: “all,” “most” (i.e., 7 or more in-person and four telephone focus groups, physicians), “several,” and “some” (“several”
  7. 7. JHQ • Web Exclusives • November/December 2007 W6-7 Figure 1. Discussion Guide for Focus Groups with Nephrologists and Non-Nephrologists I. Introduction A. Background B. My role C. Purpose of the focus group D. Tape recording of the sessions E. Ground rules F. Role of the participant G. Introduction of participants 1. First name 2. Length of time in practice II. Practice Patterns A. What changes, if any, have been made in the past 12 to 18 months in your approach to the care of chronic kidney disease patients? For each change, ask 1. Why was this change(s) implemented? 2. How was this change(s) implemented? B. What changes, if any, have been made in the past 12 to 18 months in your approach to the care of patients with any other conditions in your practice? C. Do you currently use preestablished guidelines or protocols to treat any conditions in your practice? 1. If yes a. Which conditions are guidelines or protocols used for? b. What are the most useful features, if any, of these guidelines or protocols? c. What practice improvement tools, if any, are available for you to use in implementing these treatment guidelines or protocols? (1) If any tools are available, how useful are they? (2) If no tools are available, how useful would practice improvement tools be for the guidelines or protocols that are available to you? III. Practice Dynamics—Advanced Chronic Kidney Disease (ACKD) A. Patient population 1. How significant an issue to you is ACKD? a. Why? 2. How are ACKD patients identified in your practice? a. If not mentioned: (1) Systematic versus nonsystematic (e.g., routine screening of hypertension [HTN], diabetes patients)? (2) Do you calculate glomerular filtration rate (GFR)? – What formula do you use? – What, if any, tool is used to calculate GFR? (3) When, if at all, do you list an ACKD diagnosis in your record problem list? B. Relationship with a specialist (i.e., nephrologist) 1. Referral patterns a. How often are ACKD patients referred to you by a generalist? b. Which generalists refer ACKD patients to you? c. At what point is an ACKD patient referred? (If not mentioned, when, relative to the GFR or uremic symptoms?) 2. Role of the specialist a. What role do you take in the care of ACKD patients that are referred to you? (1) Formal episodic consultation (2) Informal episodic consultation (how?) (3) Under what circumstances, if any, do you provide total care for an ACKD patient? (4) Comanagement situations – Who writes treatment orders? – As appropriate, who manages the diabetic component in an ACKD patient? – As appropriate, who manages the hypertension component in an ACKD patient? b. Is your relationship with the generalist (as described above) the same for all ACKD patients? (1) Under what circumstances, if any, is the relationship different? – Patient characteristics? – Situation dynamics? c. Are there any particular ACKD patients with whom you take less of a consultative role (e.g., GFR ≤ 30)? d. How would you describe your level of comfort with the relationship you have with the generalist(s) who refer ACKD patients to you? (1) Is it clear to you when (at what point in their condition) ACKD patients should be referred to you? (2) Is it clear to you how often ACKD patients should be referred to you? C. Treating ACKD 1. What protocol (implicit or explicit), if any, do you have for managing ACKD? a. For what aspects of ACKD do you have a management protocol? (List on a flip chart or a board) b. For each protocol, what is the source of that protocol? c. (If not mentioned above), do you have a treatment protocol for (1) Managing anemia Source of protocol (2) Managing metabolic bone disease Source of protocol (3) Managing nutrition Source of protocol (4) Blood pressure management Source of protocol continued
  8. 8. JHQ • Web Exclusives • November/December 2007 W6-8 Figure 1. Discussion Guide for Focus Groups with Nephrologists and Non-Nephrologists (continued) (5) Lipid management Source of protocol (6) Counseling and rehabilitation Source of protocol (7) Preparation for renal replacement therapy Source of protocol 2. What is the ideal situation for managing ACKD patients with regard to a. Managing anemia (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? b. Managing metabolic bone disease (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? c. Managing nutrition (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? d. Blood pressure management (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? e. Lipid management (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? f. Counseling and rehabilitation (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? g. Preparation for renal replacement therapy (1) Is this approach according to a protocol? (2) In what ways, if any, has the protocol not been as successful as you would have hoped? h. In your opinion, whom do patients look to for advice when treating these conditions (mentioned above)? 3. What aspects of caring for patients with ACKD do you find undesirable or are you uncomfortable with? a. For any aspect, ask (1) Why is that aspect undesirable, or why are you uncomfortable with it? (a) What can be done to make it more desirable or make you more comfortable? b. If not mentioned above, ask, How comfortable are you that (1) All patients are correctly identified? (a) Why is that? (2) Patients are consistently tracked? (a) Why is that? (3) Patient care is optimized (relative to the recommendations)? (a) Why is that? (4) Roles and responsibilities of the primary care provider (PCP) and staff, specialist, and the patient are clear? (a) Why is that? D. Practice improvement tools 1. For each tool, ask a. How useful would this tool be to you in managing your ACKD patients? b. In what format would this tool be most preferred? (e.g., paper, electronic)? c. As applicable, what would you like this tool to contain? d. As appropriate, how often would you like to receive the tool? e. What would you not want in regard to the tool? (1) Practice Audit (2) Renal Physicians Association Guideline (3) Tool for calculating GFR (4) Tools based on electronic medical records (5) Web-based tools (6) Flow sheets, tracking forms, or both for patients with ACKD (7) Patient information materials (What type of materials?) (8) Patient health records (9) Specialized consult forms (e.g., reason for referral, PCP expectations for ongoing management, specific feedback requested [nephrologists recommended plan—if ongoing management, who does what?]) (10) Specialized ongoing patient care communication forms (e.g., containing labs, medications, procedures, appointments) (11) ACKD evaluation clinic package (e.g., how to set up such a clinic in a PCP setting) (12) Any others that would be useful? and “some” indicate fewer than 7 physicians). Late Identification of ACKD Table 4 lists the perceptions of non-nephrologists Non-nephrologists identified individuals and nephrologists regarding identification with ACKD through annual laboratory tests and management of individuals with ACKD. for serum creatinine or screening tests for Particularly strong consensus statements or diabetes. Some of the physicians mentioned conclusions are enclosed in quotation marks in that laboratories computed patients’ glom- the discussion below. erular filtration rate (GFR). Irrespective of the
  9. 9. JHQ • Web Exclusives • November/December 2007 W6-9 method of detection, all non-nephrologists Table 2. Some Questions Posed to Focus-Group believed that they were successfully identify- Participants (Nephrologists and ing all individuals with ACKD who presented Non-Nephrologists) in their practices. Nephrologists maintained that they “always How do you identify chronic kidney disease (CKD)? calculated” GFR for their patients; however, When and why do you think CKD patients are referred to a neph- they believed that non-nephrologists “never rologist? calculate” GFR and therefore that CKD patients who are identified form “just the tip of the ice- What is your opinion about the referral process? berg of CKD, [so] we are missing 50%–70% of Do you routinely use clinical guidelines in your practice? patients with CKD.” If you do, which practice guidelines do you routinely use? A Disorganized Referral Process When the referral process was discussed, all Were you aware of a CKD guideline prior to this meeting? physicians believed that it was disorganized. If you were to use the guideline Appropriate Preparation of More specifically, issues arose surrounding the Patient for Renal Replacement Therapy (Renal Physicians (a) the timing of referral, (b) the nature of the Association, 2002), can you describe some guideline implemen- referral, (c) the process of the referral (e.g., tation tools that would assist you? (Please include suggestions what information is sent with patients), and regarding tools directed to the provider, practice, and patients.) (d) the role of the nephrologist in streamlining this process. Non-nephrologists maintained that they Table 3. Demographic and Practice Features of refer their patients to nephrologists for various Physicians Participating in Focus Groups reasons—if they themselves “do not under- stand the underlying disease,” “when the Nephrologists Non-Nephrologists patient is close to dialysis,” or “when creati- (n = 14) (n = 14) nine is above 4 mg/dL.” They were not certain Geographic region about the appropriate time to refer a patient to Northeast 5 2 South 4 6 a nephrologist. Midwest 3 2 The nature of the referral varied from the West 2 4 nephrologist’s giving a one-time consultation Location to taking over complete care of the patient. Urban 5 10 This depended on patient factors (e.g., patient Suburban 9 1 preference, insurance status), referring physi- Rural none 3 cian factors (e.g., patient load, interest in CKD, Gender availability of specialists, and relationship with Male 10 8 specialists), and nephrologist factors (e.g., avail- Female 4 6 ability, patient load, relationship with referring Academic affiliation 4 3 physicians). Most referring physicians preferred No academic affiliation 10 11 to take care of all “nonrenal” issues until their Part of a group practice 11 14 patients required dialysis, and they “never saw Number of nephrologists Question not the patient [after] they referred him or her (to a available for referring applicable for specialist).” They said that they were dissatis- advanced chronic kidney nephrologist fied with the referral process. When physicians disease (ACKD) patients group referred their patients, they believed that they Number of referring Range: 10–150 Question not were sending all the necessary information physicians Median: 40 applicable for non-nephrologist group (e.g., history, laboratory test results). Distance to a nephrology Question not appli- 0–10 miles Nephrologists received approximately two- office cable for nephrolo- thirds of patient referrals from primary care gist group physicians (PCPs) and the remainder from Proportion of individuals 30%–50% 1%–10% cardiologists and endocrinologists. Referrals with ACKD in the practice came at various stages of CKD. All neph- Time spent with individuals rologists agreed that patients were being with ACKD referred at earlier CKD stages than in the First consult 30–90 minutes 15–30 minutes past but without adequate clinical information. Follow-up 10–50 minutes 15–30 minutes
  10. 10. JHQ • Web Exclusives • November/December 2007 W6-10 Table 4. Perceptions Regarding Identification and Management of Patients with Advanced Chronic Kidney Disease (ACKD) Number of Non-Nephrologists Number of Nephrologists Perceptions Sharing the Perception Sharing the Perception 14 ≥7 <7 0 14 ≥7 <7 0 CKD patients are identified through a calculation of glomerular filtration rate X X Dissatisfied with referral process X X Dissatisfied with “education” provided by nephrologists X X Dissatisfied with overall level of ACKD patient care X X Dissatisfied with reimbursement associated with ACKD patient care X X Have difficulty in controlling blood pressure in ACKD patients X X Have difficulty in managing anemia of ACKD patients X X Have difficulty in managing bone disease X X Have difficulty in managing dyslipid- emia in ACKD patients X X Find it difficult to prepare a patient for renal replacement therapy X X Find it difficult to provide education to ACKD patients X X Nephrologists perceived that they were pri- clinical areas addressed by the published mary caregivers for most individuals with ACKD guideline: anemia, hypertension, bone ACKD. All of them insisted that they always disease, dyslipidemia, nutrition, counseling kept the referring physician aware of the and rehabilitation, and preparation for renal patient’s case. In discussions of the referral replacement therapy (RRT) (Renal Physicians process, nephrologists and non-nephrologists Association, 2002). All physicians, regardless were equally dissatisfied. of their specialty, stated that the most difficult clinical areas to manage were hypertension The Role of the Nephrologist in “Educating” and bone disease. Most non-nephrologists the Referring Physician also thought that management of anemia and Some non-nephrologists believed that neph- dyslipidemia were important issues. They rologists were “good teachers.” Others felt noted that patients who presented with mul- that they did not receive the education they tiple clinical problems and time constraints expected from nephrologists. Similarly, some prevented them from adequately addressing nephrologists believed that they were educat- each clinical problem. Nephrologists believed ing their referring physicians and that they that preparing patients for RRT was “easier had fewer problems with the referral process, said than done.” while others stated that they “could be doing All physician participants were dissatis- a better job.” Some nephrologists refrained fied with the extent to which their practices from providing education because of a fear of tracked individuals with ACKD. Nephrologists offending the referring physician. believed that the inadequate tracking was attributable to non-nephrologists’ failure to Unsatisfactory Ongoing Patient Management send patients for a regular follow-up, while The focus groups discussed each of the seven non-nephrologists believed that their patients
  11. 11. JHQ • Web Exclusives • November/December 2007 W6-11 did not adhere to advice regarding follow-up. Most physicians strongly opposed a perfor- Both groups, however, agreed that the over- mance measurement tool. The principal con- all quality of care provided for individuals cern was the nonreimbursable time and effort with ACKD was poor and that it was pos- involved in the process. The only exceptions sible to improve it with “more manpower and were two nephrologists who had sophisticated resources.” information systems in their practices and were already measuring their performance. Varying Use of Clinical Practice Guidelines All physicians also agreed that although Both groups of physicians used guidelines patient education material for CKD was avail- for management of some clinical areas; the able, it was not geared toward the average most frequently used were hypertension and patient. Participants emphasized the need for lipids guidelines. Non-nephrologists were “simple” material, especially related to dietary overwhelmed by the number, length, and issues. Finally, all physicians agreed that patient complexity of guidelines and would prefer to health records were valuable in principle, but see more concise versions. they doubted their patients’ ability to use them. Most non-nephrologists were not aware of Web-based tools for patient care were rejected any kidney disease guidelines before the focus because few patients were perceived to have groups were convened; however, nephrologists the resources or the ability to access or use mentioned that they used the Kidney Disease them. Outcomes Quality Initiative (KDOQI) guide- Table 5 provides a list of implementation lines for their dialysis patients (NKF, 2002). tools that physician groups perceived to be Although non-nephrologists were enthusiastic useful. The consensus regarding the nature of about the value of an ACKD guideline, neph- implementation tools was that they should be rologists were skeptical; they said that they paper based, simple, and brief. were generally aware of all relevant clinical issues related to CKD. Discussion Physician participants in our focus groups Tools to Help Physicians Implement Practice provided us with valuable insights regard- Guidelines ing management of individuals with ACKD, The last part of the focus group concentrat- problems with the referral process due to ed on specific tools that physicians believed the involvement of more than one physician would be useful if they were to successfully specialty, and difficulty in educating patients. incorporate recommendations of the ACKD Finally, they identified tools that they per- guideline into their practices. ceived would lead to improved CKD manage- All participating nephrologists, but not non- ment. nephrologists, believed that non-nephrologists Focus groups, in general, are used to gener- needed a tool for calculating GFR. ate new ideas and identify needs, expectations, The moderator introduced a fax-back form and issues (Fern, 2001). Physician focus groups developed by the investigators. The intent have emphasized the importance of physician of this form was to clarify the nature of the input in guideline development and imple- referral and to streamline the referral process. mentation, management of chronic conditions, The tool received a mixed reaction—most non- and circumstances that are required to improve nephrologists were not enthusiastic because of the quality of healthcare delivery (Giblin et al., a general aversion to dealing with forms, while 2004). These focus groups allowed us to under- most nephrologists liked the idea “provided stand physician perspectives on complex issues [that] the form was simple.” related to ACKD diagnosis and management A tracking sheet, or reminder, inserted in the and tools that might help them better manage patient chart was already being used by some these patients. physicians, and both nephrologists and non- We chose to conduct separate focus groups nephrologists were receptive to a similar tool, for nephrologists and non-nephrologists in provided that “[they did] not have to enter any order to encourage candid discussions of prob- data” and that there is “not more than one sheet lems related to more than one physician spe- in the chart.” On the other hand, most non- cialty involved in ACKD management. The nephrologists (but not nephrologists) thought combination of in-person and telephone focus that a concise version of the ACKD guideline groups let us exploit advantages of both tech- was an informative tool. niques. We reached all regions of the United
  12. 12. JHQ • Web Exclusives • November/December 2007 W6-12 Table 5. Non-Nephrologists’ and Nephrologists’ Perceptions Regarding the Utility of Advanced Chronic Kidney Disease Guideline Implementation Tools Number of Non-Nephrologists Who Number of Nephrologists Who Guideline Implementation Tool Perceived Utility of the Tool (n = 14) Perceived Utility of the Tool (n = 14) 14 ≥7 <7 0 14 ≥7 <7 0 Concise guidelines X X Glomerular filtration rate calculator X X for non-nephrologists Education for non-nephrologists X X Specialized consult form X X Tracking sheet X X Performance measurement (audit X X tool) Simple patient education material X X Patient health record X X Information technology–based tools X X States through telephone focus groups, and the findings of research in other areas where more relative anonymity they provided led to richer than one physician specialty is involved, espe- data. For example, participating physicians cially in the management of chronic conditions, revealed several problems they faced in man- that referral processes are especially challenging aging CKD patients, admissions we suspect (Ifudu & Friedman, 2003). If management of that few physicians would make in person. ACKD patients is to be optimized, these pro- The in-person focus groups allowed greater cesses require special attention. participant interaction, resulting in a deeper The objective of this exercise was to system- exploration of each topic. atically develop a set of tools for implement- Our focus groups highlighted the prob- ing clinical practice guidelines to optimize lem of underdetection of CKD patients, which ACKD patient management. The results of our other researchers have documented as well focus groups provide us with valuable insights (Coresh, Astor, Greene, Eknoyan, & Levey, toward this end (Table 5). In general, we noted 2003; McClellan et al., 1997). Sources of this that physicians prefer to use implementation problem are the use of serum creatinine as a tools that have proven their utility in other surrogate for GFR, and the limitations that this areas of management (e.g., reminders or track- imposes (Levey et al., 1999). However, calculat- ing sheets) (National Health Service Centre ing GFR is not a standard procedure in primary for Reviews and Dissemination, 1999). On the care (Provenzano, 2003), as the participants other hand, a new tool, the fax-back form, had confirmed. This finding underscores both the a mixed reception. Considering the evidence need for PCPs and other referring physicians to regarding inaccurate documentation in paper understand the importance of GFR calculation records, our participants’ unfavorable reaction in the first place (the role of physician educa- to a performance measurement tool may be tion) and the need for a quick GFR calculation justifiable. Improving the medical record may method (a readily available GFR calculator). be a prerequisite to widespread performance Although evidence exists that early referral measurement, and the use of information to a nephrologist improves outcomes in sub- technology should greatly simplify its process sequently dialyzed patients (Stack, 2003) and (Sugarman, 1997). slows progression of CKD (Nissenson et al., 2001; Our focus-group participants revealed some Pereira, 2002; Stack), it appears that clear direc- interesting physician perceptions about patient tion regarding the appropriate time for referral tools as well. Physicians’ lack of optimism about is needed. In addition, our results reaffirm the patient-held health records is well documented
  13. 13. JHQ • Web Exclusives • November/December 2007 W6-13 (Jeffs, Nossar, Bailey, Smith, & Chey, 1994), and focus groups apply to all chronic conditions our participants echoed that skepticism. Of where generalist-specialist interaction is criti- note is the contrasting opinion presented by cal, patient involvement is exceptionally rel- CKD patients during a set of separate focus evant, and evidence suggests that adherence groups. Our patient participants expressed a to guidelines will result in better patient out- great deal of enthusiasm for maintaining their comes. own health records. They acknowledged that We acknowledge some limitations to our their individual abilities to do so might vary study. Although the exploratory nature of focus and recognized that initiating a discussion of groups strengthens the ability to generate ideas, the records with their physicians would give their results are, by necessity, interpretive. In them an opportunity to understand their con- order to reduce the potential bias that inter- dition better. However, they also expected that pretation may introduce, and in keeping with they would need their treating physicians to be qualitative research strategies, we allowed sev- actively involved in this process. eral reviewers with different backgrounds to All physician participants agreed that interpret our results (Wish, Roberts, Besarab, & patient education material must be directed Owen, 1999). In addition, because the objective toward patient needs. Evidence regarding of this exercise was to provide inputs for the the impact of patient education and involve- process of tool development, we did not use ment on healthcare outcomes (Michie, Miles, the expensive techniques of coding data with & Weinman, 2003) indicates that these patient software. We also acknowledge the inherent and physician views are important to keep in volunteer bias that is introduced in our (and mind. all focus-group) interviews. Finally, the sample In addition to providing us with information size for our focus groups was small. However, regarding the nature of truly useful guideline these biases do not undermine our conclusions, implementation tools, our results also offer insofar as the concepts that emerged from our rich data for nephrologists, non-nephrologists, discussions provide a road map for testing the tool developers, and individuals interested in transferability of results derived from qualita- quality improvement in CKD and other com- tive studies (as opposed to generalizability plex and chronic clinical conditions. in quantitative studies) (Giacomini & Cook, As physicians who identify ACKD patients, 2000). non-nephrologists play a critical role in opti- These limitations notwithstanding, we mizing quality of care for individuals with believe that by using FPI and the informa- ACKD and can act on our results that rec- tion obtained through our focus groups, we ognize the need for early detection of CKD. have developed a set of ACKD guideline- They can also assist in streamlining the refer- implementation tools (Table 1) in a system- ral process, in turn making comanagement atic fashion (Renal Physicians Association, more systematic and effective. As key opinion 2004). The tools—a fax-back form (Figure 2), a leaders, nephrologists can use our results to patient diary (Figure 3), and an advanced CDK promote education among colleagues, set up management flow sheet (Figure 4)—address effective arrangements for comanagement, management issues critical for optimizing the and provide tools (like GFR calculators) to care of the growing population of individuals referring physicians. Finally, all physicians with CKD and other chronic conditions. sharing the responsibility of CKD patient management can lobby for the production of Acknowledgments simple patient education material that meets This work was supported by the Renal the spectrum of demands of the existing Physicians Association. The authors also patient population. acknowledge the assistance of Rebecca Gray, The relevance of our results expands beyond Karen Kroszner, and Alison Lee for technical CKD management. Problems with referrals assistance during the study and in the prepa- and communication across specialties are not ration of the manuscript. unique to CKD. Similarly, physician percep- tions regarding clinical practice guidelines and References guideline implementation tools are common Brenner, B. M., Cooper, M. E., de Zeeuw, D., Keane, W. F., Mitch, W. E., Parving, H. H., et al. (2001). Effects to all conditions. Therefore, insights from our of losartan on renal and cardiovascular outcomes in
  14. 14. JHQ • Web Exclusives • November/December 2007 W6-14 Figure 2. Fax-Back Form FAX TRANSMITTAL Date: __________________________________________________ To: ____________________________________________________ From: ___________________________________________ Fax: ___________________________________________________ Fax: _____________________________________________ Phone: _________________________________________________ Phone: __________________________________________ TO BE COMPLETED BY NEPHROLOGIST Dear Doctor _________________________________________________, Thank you for referring your patient, __________________________________________, for a nephrology consult. Your patient has been given an appointment on ___/___/___. If this time frame is not what you consider best, please let me know. The following results may be helpful to have in hand—if available, please fax to my office prior to the consult visit. ❏ CBC ❏ Serum creatinine (if available, prior results as well as current) ❏ Electrolytes, bicarbonate, BUN, calcium, phosphorus, glucose, albumin, lipid profile ❏ Urinalysis ❏ Renal ultrasound report (if available, other kidney imaging studies) Thanks again. I look forward to seeing your patient. Date: __________________________________________________ To: ____________________________________________________From: ____________________________________________ Fax: ___________________________________________________Fax: _____________________________________________ Phone: _________________________________________________Phone: ___________________________________________ TO BE COMPLETED BY REFERRING PHYSICIAN (Attach lab results and medication list if applicable) ❏ Please find attached requested labs/information. Purpose of consult: ❏ For opinion only ❏ To develop a CKD comanagement plan ❏ For comprehensive management of CKD Comments: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
  15. 15. JHQ • Web Exclusives • November/December 2007 W6-15 Figure 3. Patient Diary Patient name: Physician name: Telephone number: *GFR = Glomerular Filtration Rate. It is a key measure of your kidney function. The Renal Physicians Association has identified goals of care** for patients with Stage 4 or 5 CKD Manage your anemia • Have your doctor check for anemia (low hemoglobin [Hb]). If anemic, further tests can show why • Ask if you need iron pills. If your Hb stays low, ask if you need erythropoietin (EPO) Control your blood pressure (BP) • Have your BP checked often. If it is high, you may need to change certain lifestyle habits (diet, exercise) • If BP stays high after making changes in your lifestyle, ask if BP medication should be added • Have the nurse check your blood pressure each time you get a dose of EPO Prevent bone disease • Discuss with your doctor how to keep your bones strong • Calcium, phosphorus, and parathyroid hormone (PTH) levels will need to be measured with blood tests • Based on these blood test results, a special diet or pills may be needed Watch your diet and weight • Keep track of your body weight and albumin levels (measured with a blood test) • Maintaining good nutrition is very important; unintentional weight loss may be a sign of poor nutrition • Seeing a dietitian for hints on maintaining a healthy weight and following the right diet can be very helpful Note. Consists of three pages, one page presented. **Renal Physicians Association Clinical Practice Guideline Number 3: Appropriate Preparation of the Patient for Renal Replacement Therapy patients with type 2 diabetes and nephropathy. New Fern, E. (2001). Advanced focus group research. Thousand England Journal of Medicine 345(12), 861–869. Oaks, CA: Sage Publications. Coresh, J., Astor, B. C., Greene, T., Eknoyan, G., & Levey, Giacomini, M. K., & Cook, D. J. (2000). Users’ guides to the A. S. (2003). Prevalence of chronic kidney disease and medical literature: XXIII. Qualitative research in health care decreased kidney function in the adult U.S. popula- B. What are the results and how do they help me care for tion: Third national health and nutrition examination my patients? Evidence-Based Medicine Working Group. survey. American Journal of Kidney Diseases, 41(1), 1–12. Journal of the American Medical Association, 284(4), 478–482.
  16. 16. JHQ • Web Exclusives • November/December 2007 W6-16 Figure 4. Advanced Chronic Kidney Disease Management Flow Sheet Patient Name: __________________________________________________________________ Action Measure (Area of Minimum Guidance) Target Frequency Date Date Date Date Date Date Date Date Date Date Date Date Depends on Creatinine/ Decrease stage, rate of Glomerular rate of change, and filtration rate GFR clinical (GFR) decline factors Hemoglobin 11–12 Every 3 (Anemia) g/dL months Bicarbonate >22 Every 3 (Bone disease) mmol/L months Phosphorus <4.5 Every 3 (Bone disease) mg/dL months Low phosphorus diet prescribed Phosphate binder prescribed Calcium 8.5–10.5 Every 3 (Bone disease) mg/dL months Not >100 Every 3 pg/mL or months if Ca iPTH 1.5x or PO4 is (Bone disease) normal abnormal 25 (OH) Vitamin D >30 If iPTH is (Bone disease) mg/mL abnormal Blood pressure 130/80 Every 3 (Hypertension) mm Hg months ACEI or ARB dose increased or new agent added Note. A portion of the flow sheet is presented. Shaded areas indicate quality indicators—see Evaluation Tool: Patient Management. Ca = calcium; PO = phosphorus; OH = hydroxy; iPTH = immunoreactive parathyroid hormone; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker. Giblin, T. B., Sinkowitz-Cochran, R. L., Harris, P. L., Matchar, D. B., Patwardhan, M. B., Samsa, G.P., & Haley, Jacobs, S., Liberatore, K., Palfreyman, M. A., et al. W. E. (2006). Facilitated process improvement: An (2004). Clinicians’ perceptions of the problem of anti- approach to the seamless linkage between evidence microbial resistance in health care facilities. Archives of and practice in CKD. American Journal of Kidney Diseases, Internal Medicine, 164(15), 1662–1668. 47(3), 528–538. Ifudu, O., & Friedman, E. A. (2003). Managing chronic renal Mays, N., & Pope, C. (1995). Rigour and qualitative insufficiency—Intertwined roles of non-nephrologist research. British Medical Journal, 311(6997), 109–112. and nephrologist. Journal of the National Medical McClellan, W. M., Knight, D. F., Karp, H., & Brown, W. W. Association, 95(1), 43–54. (1997). Early detection and treatment of renal disease Jeffs, D., Nossar, V., Bailey, F., Smith, W., & Chey, T. in hospitalized diabetic and hypertensive patients: (1994). Retention and use of personal health records: A Important differences between practice and published population-based study. Journal of Pediatrics and Child guidelines. American Journal of Kidney Diseases, 29(3), Health, 30(3), 248–252. 368–375. Levey, A. S., Bosch, J. P., Lewis, J. B., Greene, T., Rogers, N., McCrory, D., Klassen, P., Rutschmann, O., Coladonato, & Roth, D. (1999). A more accurate method to estimate J., Yancy, W., Reddan, D., et al. (2002). Evidence glomerular filtration rate from serum creatinine: A new report: Appropriate patient preparation for renal replace- prediction equation. Modification of diet in renal disease ment therapy. Final report. Rockville, MD: Renal study group. Annals of Internal Medicine, 130(6), 461–470. Physicians Association. Retrieved October 15, 2007,
  17. 17. JHQ • Web Exclusives • November/December 2007 W6-17 from www.renalmd.org/publications/downloads/ Schoolwerth, A. C., Engelgau, M. M., Hostetter, T. H., FinalEvReportandTables.pdf. Rufo, K. H., Chianchiano, D., McClellan, W. M., et Michie, S., Miles, J., & Weinman, J. (2003). Patient- al. (2006, April). Chronic kidney disease: A public centeredness in chronic illness: What is it and does it health problem that needs a public health action plan. matter? Patient Education and Counseling, 51(3), 197–206. Preventing Chronic Disease, 3(2), A57. National Health Service Centre for Reviews and Stack, A. G. (2003). Impact of timing of nephrology refer- Dissemination. (1999). Effective health care: Getting evi- ral and pre-ESRD care on mortality risk among new dence into practice. Retrieved August 18, 2004, from ESRD patients in the United States. American Journal of www.york.ac.uk/inst/crd/ehc51.pdf. Kidney Diseases, 41(2), 310–318. National Kidney Disease Education Program. (2006). Web Sugarman, J. R. (1997). Challenges in measuring adherence site: www.nkdep.nih.gov. to clinical practice guidelines. Journal of the American National Kidney Foundation. (2002). KDOQI clinical prac- Board of Family Practice, 10(3), 237–239. tice guidelines for chronic kidney disease: Evaluation, Wish, J., Roberts, J., Besarab, A., & Owen, W. F., Jr. (1999). classification, and stratification. American Journal of The cost of implementing the dialysis outcomes quality Kidney Diseases 39, S1–S246. initiative clinical practice guidelines. Advances in Renal Nissenson, A. R., Collins, A. J., Hurley, J., Petersen, H., Replacement Therapy, 6(1), 67–74. Pereira, B. J., & Steinberg, E. P. (2001). Opportunities for improving the care of patients with chronic renal insufficiency: Current practice patterns. Journal of the Authors’ Biographies American Society of Nephrology, 12(8), 1713–1720. Meenal B. Patwardhan, MD MHSA, is an assistant Obrador, G. T., Arora, P., Kausz, A. T., Ruthazer, R., Pereira, research professor in the Division of General Internal B. J., & Levey, A. S. (1999). Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease Medicine in the department of medicine at Duke University population. Kidney International, 56(6), 2227–2235. Medical Center, a research associate in the Durham V A Patwardhan, M. B., Samsa, G. P., Matchar, D. B., & Haley, Center for Health Services Research in Primary Care, W. E. (2007). Advanced chronic kidney disease practice and a senior fellow and director of operations at the Duke patterns among nephrologists and non-nephrologists: Center for Clinical Health Policy Research. A database analysis. Clinical Journal of the American Society of Nephrology [Published ahead of print]. Doi: David B. Matchar, MD, is director of the Duke Center for 10.2215/CJN.02600706. Retrieved January 3, 2007, from Clinical Health Policy Research, professor of medicine at www.cjasn.asnjournals.org/cgi/content/abstract/ the Duke University School of Medicine, and a practicing CJN.02600706v1. internist at the Durham V Medical Center. A Pereira, B. J. G. (2002). Overcoming barriers to the early detection and treatment of chronic kidney disease William E. Haley, MD, is an assistant professor of medi- and improving outcomes for end-stage renal disease. cine at Mayo Medical School, Rochester, MN, and chair American Journal of Managed Care, 8(4 Suppl), S122–135; of the Division of Nephrology and Hypertension at Mayo quiz S136–S139. Clinic, Jacksonville, FL. Provenzano, R. (2003). Treating chronic kidney disease. American Journal of Managed Care, Spec. No. 3–7, discus- Gregory P. Samsa, PhD, is an associate professor in sion 17–20. the department of biometry and bioinformatics at Duke Renal Physicians Association. (2002). Renal Physicians University, associate director of the Center for Clinical Association’s clinical guideline number 3: Appropriate Health Policy Research, and associate director of the preparation of the patient for renal replacement therapy. Biometry Training Program, Durham, NC. He is also the Rockville, MD: Author. lead methodologist for the Duke Evidence-Based Practice Renal Physicians Association. (2004). The advanced CKD Center. management toolkit: Improving management and care of advanced chronic kidney disease patients. Rockville, For more information on this article, contact Meenal MD: Author. Retrieved October 15, 2007, from www. Patwardhan at Meenal.P@duke.edu. renalmd.org/toolkit.
  18. 18. JHQ • Web Exclusives • November/December 2007 W6-18 q&a: Tracy Sklar On Advancing Improvement in Acute Care Wayne E. Soo Hoo, Interviewer q What strategies have been successful in your leadership of the quality programs at Catholic Healthcare West (CHW)? Tracy Sklar, MSc MBA, is the vice president for quality and ser- vice excellence in the care management department of Catholic Healthcare West (CHW). She has worked in the care management a One of CHW’s core values is collabora- tion. I believe that adhering to this value has helped us achieve excellence in the quality of care delivered to our patients. We department for 6 years and at CHW for more than 18 years. Sklar is a highly effective process facilitator with strong analytical skills, and she has a well-documented record of leading successful clinical improvement projects that have resulted in both improved use four approaches to quality improvement. First, through the leadership of our governing patient outcomes and cost savings. She has developed and led a board and senior leadership team, the organi- number of internal hospital collaboratives for improvement. One zation establishes specific performance goals such collaborative, which focused on improving care for patients on quality, safety, and service with detailed in the intensive care unit, was presented at the annual meeting of definitions and clear evidence-based strate- gies that result in improvement. Second, we the Institute for Healthcare Improvement (IHI); the 50% reduc- conduct systemwide projects on a variety of tion achieved in ventilator-associated pneumonia was subsequent- clinical topics where hospitals can learn from ly highlighted on IHI’s Web site. The results from another internal national experts and openly share data and collaborative for pneumonia care were published in the Journal of best practices. For example, each of our 42 hospitals knows how the others perform on Clinical Outcomes Management. Sklar is also providing leadership quality measures and therefore can engage to CHW’s initiative to improve patient satisfaction. The goals for with those performing at higher rates. Third, this program are to achieve the national 80th percentile in perfor- we have a number of clinical councils (com- mance. prised of clinical functional leaders including physicians) that focus on achieving improve- ments across the system. And fourth, CHW scientific methods with process improvement Key Words annually sponsors a Quality Summit to cel- ebrate successes and share best practices. The to improve the care for our patients. Because acute care Quality Summit is quite popular—in the past of my interest and enthusiasm, the hospital performance improvement few years we’ve received more than 100 best- asked me to help take a leading role in devel- practice submissions. oping and implementing a training program for quality improvement. From there my role at the hospital evolved into quality specialist, q How did your career path take you from your clinical role to your current position in quality management? then director, and ultimately vice president for quality at CHW. a When I was working as a clinical dieti- tian, I participated in quality improve- ment training. At this time, total quality management and continuous quality improve- q To what extent have you been involved with the Institute for Healthcare Improvement (IHI), and how have you implemented IHI innovations within the CHW Journal for Healthcare Quality Web Exclusive Vol. 29, No. 6, pp. W6-18–W6-20 www.nahq.org/journal/online/ ment methods were just being introduced into multihospital system? © 2007 National Association for Healthcare Quality healthcare. Work in quality was new to me, and I thought it was great because it combined
  19. 19. JHQ • Web Exclusives • November/December 2007 W6-19 a We have found IHI to be a valuable part- ner for quality improvement, and we are involved with the organization at both q Sustaining improvement in performance improvement is difficult work. What has helped you be successful? a the system level and the individual hospital level. At the system level, CHW has partnered We’re fortunate that the goals of quality, with the faculty of IHI to develop internal safety, and service are a high priority for collaborative projects. Our most recent col- Lloyd Dean, our chief executive officer laborative includes projects to improve care and president. He is an unflinching champion in our intensive care units and end-of-life care. of these goals and communicates his com- In addition, a number of our hospitals have mitment and dedication in many forums. His enrolled in an IHI-sponsored collaborative to personal commitment amplifies the expecta- improve care. tions throughout the organization. In addi- tion, under the clinical leadership of George Bo-Linn, MD, our chief medical officer, expec- q What innovations in quality management are you implementing in your organiza- tion? tations for excellence throughout our entire system are at the highest level. This cascade throughout the organization motivates and engages leaders, employees, and physicians a A number of systemwide projects focused on improving the care and services deliv- ered to our patients are under way. For to achieve and sustain a high level of perfor- mance for our organization. q example, we are implementing a quality man- agement information technology system that What do you believe is the most impor- will share a single database and allow for tant skill in a healthcare quality profes- benchmarking across the system at the provider sional’s toolbox? a specialty level. We have projects to decrease vari- ation and improve efficiency of care delivered, Intelligence, humor, flexibility, and a projects to achieve excellence in public report- personal commitment to excellence all ing initiatives as part of the Hospital Quality help healthcare quality professionals be Alliance Project, and projects to achieve the goals successful in their work. identified in IHI’s 5 Million Lives Campaign. Our quality staff at each facility meets monthly to share best practices, discuss common issues, and identify strategies for improvement. q Adopting best practices and spreading innovation is a theme in your work at CHW. How do you select and prioritize q improvement projects? Describe strategies you have used to achieve organizational alignment and support for performance improvement. a Four considerations help establish pri- orities for quality for CHW. First is a our mission. Our founding congrega- A number of factors contribute to orga- tions of women religious have established nizational alignment for CHW. Initially, this ministry to improve the health of the the CHW board of directors establish- communities we serve, with special atten- es our strategic focus. Our current strategy, tion to the underserved. Our hospitals focus Horizon 2010, aligns our entire organization on giving each patient excellent care, every on growth, innovation, and leadership for time. Our palliative care improvement proj- improved access and excellent quality. From ect, which includes a component that spe- this strategic perspective, we work to meet and cifically addresses spiritual care at the end of exceed clearly defined goals with initiatives to life, is one example. Another example is our achieve improvements in quality, safety, and innovative Community Needs Index (recently service with specific numeric performance published in Health Progress), which uses a objectives. Having the whole system “rowing scientific approach to identify health needs for in the same direction” helps us maintain a every zip code in the United States. It is used clear focus on quality improvement.
  20. 20. JHQ • Web Exclusives • November/December 2007 W6-20 by hundreds of providers throughout the The fourth consideration is transparent country and is influencing emerging biparti- patient outcomes. The public reporting expec- san legislation. tations for hospitals have increased exponen- A second consideration for prioritizing tially. We believe that transparency in quality improvement projects is regulatory require- is very important for consumers and that they ments. A number of priorities have been estab- should have access to information that will lished by the regulatory agencies involved in help them make better-informed healthcare healthcare, such as the Joint Commission and decisions. We are also engaged in a number the Centers for Medicare & Medicaid Services. of projects with outcomes that are reflected in As in most hospital systems, our goals must publicly available forums. and do align with these priorities. Wayne E. Soo Hoo, PhD RN CPHQ, is the director of A third consideration is the variations quality and patient safety at Mercy San Juan Medical among hospitals. We assess performance Center in Carmichael, CA, a faculty member at the across our hospitals in a number of areas. We University of Phoenix—Sacramento, and a member of JHQ’s editorial board. look for opportunities for improvement where wide variation exists between hospitals and where we see opportunities to have a positive impact on a large number of patients.