Like all healthcare, dialysis programs are undergoing a revolution in accountability. The government, accrediting and regulatory agencies, payers, and patients are holding healthcare organizations accountable for the delivery of high-quality, low-cost healthcare. Healthcare providers are being asked to explain the rationale behind their decisions and plans of care. Increased competition in the managed care environment also demands that providers be responsive to quality and cost issues. Continuous quality improvement (CQI) is a method used to address those concerns. CQI must be supported by a leadership style of total quality management (TQM), in which all members of the organization are motivated to go beyond meeting minimum standards by complying with regulatory requirements as they continually evaluate their performance with the goal of improving care and outcomes.
What is the medicare improvements for patients and providers act?
The Medicare Improvements for Patients and Providers Act (MIPPA) is legislation that was approved and passed by Congress in July 2008. This act has significant implications for the nephrology community. The core of the act is the development of a case-mix adjusted bundled payment rate, a pay for performance quality incentive, and an educational condition to help patients with chronic kidney disease (CKD) manage their disease process. This is the only modification in the payment rate since the composite rate was introduced in 1983.
The composite rate is a fixed rate that Medicare pays for each dialysis treatment. This fixed or composite rate covers all services rendered, including supplies, equipment, and medications associated with the dialysis treatment. Since the composite rate was established, many new treatment-related pharmaceuticals have become part of the standard dialysis treatment. These additional drugs, such as erythropoiesis-stimulating agents, vitamin D, and iron, were not included in the original composite rate and have been billed for separately, over and above the composite rate. Additionally, many new laboratory studies and supplies did not exist when the composite rate went into effect, so these too have been billed separately. With the increase in Medicare use for end-stage renal disease (ESRD) services, MIPPA has charged the Centers for Medicare & Medicaid Services (CMS) to develop a new bundled payment that will include the additional drugs and laboratory services. This new rule will also align dialysis facility payments based on quality performance measures. The new payment system is being phased in over a period of three years, beginning in January 2011.
What is continuous quality improvement?
CQI is the ongoing process of identifying opportunities to improve quality. It involves collecting data on the current situation, identifying ways to improve performance, introducing new and better approaches and methods to achieve desired outcomes, and then evaluating the interventions. When CQI is operating as intended, important aspects of care in need of improvement are identified before problems occur. All personnel contribute to CQI by being vigilant in recognizing care practices in need of improvement. A patient-centered perspective and questioning (e.g., “What about my work interferes with my ability to do what needs to be done to have the best possible outcome for patients?”) are effective ways to identify practices in need of improvement. The goal of CQI is to use data to make objective decisions without assigning blame or finding fault.
What is the origin of continuous quality improvement?
Quality management efforts began in manufacturing, where the focus was on product inspection. Quality management experts, such as W. Edwards Deming, recognized that it was not enough simply to evaluate the end product. He introduced the principles of CQI to improve and manage the production processes used to achieve a quality product.
What is quality assessment and performance improvement?
Quality Assessment and Performance Improvement (QAPI) is the name given by CMS to an internal program that ESRD facilities must develop to promote continuous improvement and outcomes (Box 24-1).
Box 24-1 V626 QAPI Condition Statement
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 program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.
From The Centers for Medicare & Medicaid Services (CMS) Interpretive Guidance, April 2008.
Quality of care issues to address include, but are not limited to, dialysis adequacy, dialyzer reuse program, nutritional status, anemia management, vascular access, bone disease management, infection control, medical injuries and errors, patient education, patient survival, vaccinations, and physical and mental functioning. Facilities are expected to prioritize those areas affecting patient safety. The Measures Assessment Tool is a reference list of acceptable standards and values for clinical and quality outcomes (Table 24-1). CMS requires that all facilities have a written plan describing their QAPI program. Facilities are also required to constantly monitor their performance and to make performance improvements as needed using quality indicators or performance measures. Action plans must be prioritized and action that results in performance improvement must be taken.
Table 24-1 MEASURES ASSESSMENT TOOL
What are the basic tenets of quality management?
Efforts to manage quality in healthcare continue to be influenced in particular by three sets of guides: Deming’s 14 points; Donabedian’s structure-process-outcome framework; and the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 10 steps. Basic tenets of CQI and TQM are a focus on customers, broadly defined to include personnel and patients, and a commitment to gather and use data to identify opportunities to improve quality outcomes by modifying processes that result in higher-quality care at less cost. Efforts to achieve quality are dynamic and continual and everyone in the organization is involved and responsible. Failures in quality are more often due to flaws in processes than to the failure of people doing the work.
Why is continuous quality improvement relevant for healthcare and for dialysis programs?
The healthcare industry is one of the largest and most costly industries in the U.S. CQI was introduced to the healthcare industry in part as an effort to slow the ever-increasing percentage of the country’s gross domestic product devoted to healthcare. Medicare spending on hemodialysis totaled nearly $17.6 billion in 2007, a 2.9% increase from the previous year. The annual cost for peritoneal dialysis reached $949 million in 2007 and the annual cost for transplantation rose 1.1% to $1.9 billion (U.S. Renal Data System, 2009). Care provided to patients with CKD who require maintenance dialysis is costly. Dialysis is provided to about 437,000 Americans at an annual cost of $23.9 billion (U.S. Renal Data System, 2009). The cost of dialysis care mandates efforts to decrease costs without sacrificing quality of care.
What is the connection between quality and cost?
Healthcare personnel are committed to providing high-quality care to patients. Consideration of the costs of that care has not always been attended to, and providers may not realize that poor care is costly. For example, if a satisfactory dialysis is not achieved for any number of process or system reasons, the patient may have outcomes that require hospitalization for emergency treatment and additional dialysis. The end result is increased cost and poor financial performance.
How is continuous quality improvement different from quality assurance?
Quality assurance (QA) was an early effort to address quality care issues in healthcare. QA, initiated in response to requirements of accreditation organizations, tended to use retrospective data collection, in which audits of medical records identified problems. These audits evaluated documented, existing problems, but improved quality of care did not necessarily result. CQI is a more proactive method, focused on seeking every opportunity to improve processes and systems to achieve quality outcomes. Concurrent collection of data for analysis is a vital aspect of CQI. The focus of CQI is evaluation of interventions to improve quality rather than documentation of problems.
Does continuous quality improvement meet a need in dialysis facilities?
As a high-volume, high-risk, problem-prone, high-cost healthcare program, dialysis is a model for CQI. Dialysis facilities can use CQI techniques to identify processes in need of improvement, implement interventions or corrective actions, and evaluate cost and quality outcomes.
What continuous quality improvement concepts and terms are important to understand?
A process is a series of interrelated activities designed to achieve a desired outcome or goal. Processes are those things that dialysis personnel do to achieve well-dialyzed patients. Preparing the dialyzer, assessing the patient, and conducting the treatment with vigilant surveillance of both the patient and the machine are examples of processes that influence how well the patient is dialyzed.
Standards define quality by specifying rules that apply to key processes and the results expected. They are written values communicated to all members of the organization. Professional organizations that establish standards for dialysis nurses include the American Nephrology Nurses’ Association (ANNA) Standards of Clinical Practice for Nephrology Nursing. Such standards specify a desired patient outcome (the patient will be free of vascular access complications); identify the nursing management aspects of care, including assessment parameters (assess vascular access for patency and evidence of complications) and interventions (use aseptic technique in handling vascular access); and implement patient teaching.
Clinical indicators are valid and reliable measures used to evaluate important patient care services. They are events that are compared to some specified universe of events to encourage a focus on desired outcomes. Individual providers and dialysis facilities are encouraged to identify indicators relevant for specific settings. Organizations involved in specifying indicators are the JCAHO, the National Committee for Quality Assurance (NCQA), and the ESRD networks. An indicator for a dialysis facility might be the number of times it is necessary for personnel to use more than one needle per venipuncture to initiate dialysis as compared with the total number of venipunctures done.
A benchmark is a frame of reference for clinical practice. It is an objective way to compare a facility’s processes and outcomes with its own past performance or with external standards. A benchmark can be the gold standard or the industry’s best practice. Benchmarking is a goal-setting process that recognizes that providers and the internal organization may not have the best answers for the problem being addressed. It is a process of comparing the care provided and its outcomes with what is considered the best. An example of a benchmark for a dialysis facility might be to compare the average delivered dose of dialysis (Kt/V) with what the industry has set as the standard.
An outcome is the result obtained from some action or intervention. The outcome must specify who will do what and by what measurement within a specific period. For instance, a dialysis facility might identify the following outcome: personnel will reduce the number of second sticks required to initiate dialysis to 5% within three months following a skill refinement workshop.
What are some tools used in continuous quality improvement?
Quality improvement efforts use the scientific method to search for, find, and fix the root cause of a problem. FOCUS is a CQI tool used to examine and analyze a specific process.
The first step is to find a process to improve by analyzing data. Statistical control is used to distinguish between common and special causes of variation in processes. Data are displayed in control charts to track performance. Variations outside of the control limits are special cause variances and require investigation. For more detailed instruction on the use of statistical control and other tools, such as flowcharts, Pareto charts, cause-and-effect (fishbone) diagrams, and run charts, refer to a CQI reference text.
The next step is to organize a team to work together to improve the situation.
Clarify the problem by collecting and analyzing data specific to the process being targeted for improvement. A cause-and-effect diagram might be useful in this step.
To truly understand, health providers examine data for the causes of variation and the changes over time.
The final FOCUS step is to select a method of improving outcomes and initiate the plan-do-check-act (PDCA) cycle of CQI.
What is the plan-do-check-act cycle?
PDCA stands for plan-do-check-act and is a framework for implementing the methods to improve outcomes selected during the FOCUS process.
Plan, the first step in instituting a change for improvement, requires an investment of time because a hastily determined solution may not produce the desired result. The use of brainstorming techniques encourages all members of the team to contribute ideas to the plan. Reviewing relevant literature is a critical element of planning. One outcome of planning by the multidisciplinary team may be a decision to develop a clinical care pathway or to adopt a clinical practice guideline as a way to improve the quality and cost outcomes of an important aspect of care.
When a plan is agreed upon, the second phase of PDCA—do—is applied. Typically, do means implementing an intervention and conducting a pilot study to see if the change is effective.
During the check phase, results of the trial are checked against the objectives of the plan and the plan is modified as needed.
The final phase of the PDCA cycle is act, in which the findings of the pilot study guide implementation of solutions in a more comprehensive, facility-wide initiative. Ongoing monitoring to ensure that improvement persists over time is necessary.
What are the foci of the end-stage renal disease networks’ key indicators?
The ESRD networks’ care indicators are adequacy of dialysis, desirable hemoglobin value, optimal nutritional status, and control of blood pressure. Reports generated can be used by dialysis facilities to compare their results with national findings, or benchmarks. These data can then lead to quality improvement projects designed to improve patient care within a facility.
The ESRD networks are involved with several other CQI projects. One is Fistula First, which began in 2002 with the CMS and the Institute for Healthcare Improvement developing an ESRD network–based improvement project for vascular access. The National Vascular Access Improvement Initiative is a three-year project that involves increasing arteriovenous fistula rates in the U.S.
The ESRD Clinical Performance Measures Project is another collaborative CQI effort between CMS, the ESRD networks, and dialysis facilities. This project involves an assessment of the care provided for adult in-center hemodialysis patients and all pediatric patients on dialysis in the U.S. The collaborative compiled a report in 2008 and described the findings of five major domains of care: adequacy of dialysis, anemia management, nutritional status, bone and mineral metabolism, and vascular access. This project is in its fifteenth year.
Does the national kidney foundation have a quality improvement initiative?
In March 1995, the National Kidney Foundation (NKF) established a Kidney Disease Outcomes Quality Initiative (KDOQI) to develop evidence-based clinical practice guidelines to improve the care of ESRD patients. The guidelines were completed in 1997 and have been translated into practice through professional education programs. Adoption of the guidelines will be evaluated for their effect on patient outcomes.
Does everyone agree with the quality improvement movement in healthcare?
Some healthcare providers resist quality improvement efforts because they believe that the quality of their practice is ensured by their professionalism. Some healthcare professionals resent what they perceive to be external interference and control. Still others believe that the time required for quality improvement is counterproductive. These negative impressions and resistance will diminish over time when they are countered successfully with a patient-centered perspective and acceptance of the goal of CQI to use data to improve quality and cost outcomes of care, as well as through positive experiences with an effective CQI program.
How can i learn more about continuous quality improvement and total quality management in healthcare?
Books, journals, the Internet, and professional organizations, such as ANNA, are great resources for additional information about quality healthcare and the specific techniques of CQI and TQM. Your ESRD network and the NKF are other good sources for information on quality improvement.