Fistula First: AV GraftFistula First: AV Graft Conversion Projectj

S tl (L ) K h QI Di tSvetlana (Lana) Kacherova, QI DirectorLisle Mukai, QI Coordinator

ESRD Network 18

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ESRD Network 18October 22, 2008

Special Acknowledgement forSpecial Acknowledgement forContent Contributions:Content Contributions:FFBI Leadership GroupFFBI Leadership Group

RMS Lif li IRMS Lif li IRMS Lifeline, Inc.RMS Lifeline, Inc.DaVita, Inc.DaVita, Inc.

John White RN ManagerJohn White RN ManagerJohn White, RN, Manager, John White, RN, Manager, Outreach and EducationOutreach and Education

Laura AdamsLaura AdamsIrina Goykhman, RN, MBAIrina Goykhman, RN, MBA

Lynda K. Ball, RN, BSN, CNNLynda K. Ball, RN, BSN, CNNi ki k

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QI Director, ESRD Network 16QI Director, ESRD Network 16

Fistula First Breakthrough Initiative Fistula First Breakthrough Initiative (FFBI) Partners(FFBI) Partners(FFBI) Partners(FFBI) Partners

Di l i f ili iDi l i f ili iDialysis facilitiesDialysis facilitiesDialysis patientsDialysis patientsN h l i tN h l i tNephrologistsNephrologistsSurgeonsSurgeonsCMSCMSCMSCMSESRD NetworksESRD NetworksState Survey AgenciesState Survey AgenciesState Survey AgenciesState Survey AgenciesQIOsQIOsAnd many more!And many more!

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And many more!And many more!

“Fistula First” GOAL“Fistula First” GOAL

Goal is to maximize autogenous AVFGoal is to maximize autogenous AVFGoal is to maximize autogenous AVF Goal is to maximize autogenous AVF construction & success rate…..construction & success rate…..

To achieve in the shorter term (2006) the initialTo achieve in the shorter term (2006) the initialTo achieve in the shorter term (2006) the initial To achieve in the shorter term (2006) the initial K/DOQI minimum benchmark of AVF use in K/DOQI minimum benchmark of AVF use in 40% of prevalent patients40% of prevalent patients40% of prevalent patients….40% of prevalent patients….

And in the longAnd in the long--term (2009), a 66% AVF rate in term (2009), a 66% AVF rate in l t ti tl t ti tprevalent patientsprevalent patients

Additional Goal: Reduce Catheter Use!Additional Goal: Reduce Catheter Use!4

Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)

CMS goalCMS goal –– 66% by June 30 200966% by June 30 2009CMS goal CMS goal 66% by June 30, 200966% by June 30, 2009Yearly Network 18 goal Yearly Network 18 goal –– 55.1 %55.1 % by June by June 30 200930 200930, 200930, 2009Yearly Network Stretch Goal Yearly Network Stretch Goal –– 56.0%56.0% by by June 30 2009June 30 2009June 30, 2009June 30, 2009August 2008 AVF rates: NW 18 August 2008 AVF rates: NW 18 –– 53.7%53.7%

USUS 50 7%50 7%US US –– 50.7%50.7%

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Tools & Best Practices:Tools & Best Practices:Fistula First Change ConceptsFistula First Change Concepts

1.1. Routine CQI Review Routine CQI Review 6.6. Secondary AVFs in Secondary AVFs in of vascular accessof vascular access

2.2. Timely referral to Timely referral to nephrologistnephrologist

AFG patientsAFG patients7.7. AVF AVF

evaluation/placementevaluation/placementnephrologistnephrologist3.3. Early referral to Early referral to

surgeon for “AVFsurgeon for “AVF

evaluation/placement evaluation/placement in catheter ptsin catheter pts

8.8. Cannulation trainingCannulation trainingsurgeon for AVF surgeon for AVF Only”Only”

4.4. Surgeon SelectionSurgeon Selection

8.8. Cannulation trainingCannulation training9.9. Monitoring and Monitoring and

maintenancemaintenance5.5. Full range of Full range of

appropriate surgical appropriate surgical approachesapproaches

10.10. Continuing EducationContinuing Education11.11. Outcomes feedbackOutcomes feedback

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approachesapproaches

Improvement in Improvement in Prevalent Prevalent AVF AVF

70 0%

Rates Rates by ESRD Networkby ESRD NetworkFFBI AVF goal 66%66%

50.0%

60.0%

70.0%

as

g

30.0%

40.0%

rcen

t Fist

ula

10.0%

20.0%Per

0.0%5 8 13 11 6 9 10 14 3 4 12 US 7 18 17 1 2 15 16

ESRD Networks Jan-03 Dec-07

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ESRD Networks Jan-03 Dec-07

FFBI AccomplishmentsFFBI AccomplishmentsFFBI AccomplishmentsFFBI AccomplishmentsWebsite Updates Ongoing (fistulafirst.org)C l d f i l tiCalendar of upcoming vascular meetings (including Networks)Tab for Patient Education materials (patient and (pprofessionals)New interventionist videos uploadedC t id k h f (M )Country-wide workshop for surgeons (May)• More Cannulation DVD reproduction in the worksDistribution of new tools to Networks:FF Provider Resource List and FAQsFF P ti t R Li t

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FF Patient Resource List

FFBI Accomplishments (cont).FFBI Accomplishments (cont).FFBI Accomplishments (cont).FFBI Accomplishments (cont).

Information sheets on Change Concepts #6Information sheets on Change Concepts #6 & #9 Monitoring and surveillance flowchart (CC#9)(CC#9)Secondary AVF Protocols (CC#6)Secondary AVF Sleeves Up ExamSecondary AVF Sleeves Up Exam Checklist Access Managers (CC#6) AdditionalAccess Managers (CC#6) Additional Buttonhole slide set (sharp needles)

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FFBI Strategies to increase AVF FFBI Strategies to increase AVF ggrate and reduce catheter rate:rate and reduce catheter rate:

Networks should mount an effort to re- educate and provide feedback on Change Package, to alland provide feedback on Change Package, to all Providers and Clinics that are below the mean, including the laggards……attempt to focus on gaps in education andperformanceperformanceEveryone focus on Change Concepts #6 & #7 –and related FF protocols (fistulafirst.org)

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Strategies to increase Secondary Strategies to increase Secondary Fistulae:Fistulae:

Re-evaluation of all patients for AVF options:Re-evaluation of all patients for AVF options:Conversion of existing AVG to AVF, utilizing outflow vein of graft for AVF where feasibleoutflow vein of graft for AVF where feasible OR:Exam & Vessel Mapping for alternate options pp g pSecondary A-V Fistula Options K/DOQI guideline 29: Every patient should beK/DOQI guideline 29: Every patient should be evaluated for a secondary fistula after each episode of graft failure

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V626 QAPI Condition StatementV626 QAPI Condition StatementQQ

The dialysis facility must develop implementThe dialysis facility must develop implementThe dialysis facility must develop, implement, The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, maintain and evaluate an effective, data driven, quality assessment and performance improvement quality assessment and performance improvement q y p pq y p pprogram with participation by the professional program with participation by the professional members of the interdisciplinary team...members of the interdisciplinary team...…The dialysis facility must maintain and …The dialysis facility must maintain and demonstrate evidence of its quality demonstrate evidence of its quality i t d f i ti t d f i timprovement and performance improvement improvement and performance improvement program for review by CMSprogram for review by CMS

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Condition 494.110:Condition 494.110:Q lit A t d P fQ lit A t d P fQuality Assessment and Performance Quality Assessment and Performance

Improvement Project (Improvement Project (QAPI)QAPI)Interdisciplinary team (IDT)Interdisciplinary team (IDT)Must report problems to Medical Director andMust report problems to Medical Director andMust report problems to Medical Director and Must report problems to Medical Director and QAPIQAPIOutcomeOutcome-- focusedfocusedOutcomeOutcome focused focused Process continuous & onProcess continuous & on--goinggoingUse community accepted standards as targetsUse community accepted standards as targetsUse community accepted standards as targetsUse community accepted standards as targetsInclude patient satisfaction, infection control, Include patient satisfaction, infection control, medical injuries & medication errorsmedical injuries & medication errors

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medical injuries & medication errorsmedical injuries & medication errorsPlan/Do/Check/Act: Close the loop!Plan/Do/Check/Act: Close the loop!

PDCA /PDSA StylePDCA /PDSA StylePDCA /PDSA StylePDCA /PDSA Style

PLANACT

DOCHECK/S Y/STUDY

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Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe ProgressThe ProgressThe Progress

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Performance Measures Performance Measures

(V629) Adequacy Kt/V URR(V629) Adequacy Kt/V, URR

(V630) Nutrition Albumin, body weight

(V631) Bone disease PTH Ca+ Phos(V631) Bone disease PTH, Ca+, Phos

(V632) Anemia Hgb, Ferritin

(V633)V l Fi t l th t t(V633)Vascular access Fistula, catheter rate

(V634) Medical errors Frequency of specific errors

V635) Reuse Adverse outcomes

(V636) Pt satisfaction Survey scores

17(V637) Infection control Infections, vaccination status

Monitoring Performance Monitoring Performance IIImprovementImprovement

(V638) The facility must:(V638) The facility must:(V638) The facility must:(V638) The facility must:Continuously monitor its performanceContinuously monitor its performanceTake actions that result in performanceTake actions that result in performanceTake actions that result in performance Take actions that result in performance improvementimprovementTrack to assure improvements are sustained overTrack to assure improvements are sustained overTrack to assure improvements are sustained over Track to assure improvements are sustained over timetime

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Inclusion Criteria for Inclusion Criteria for Participating FacilitiesParticipating Facilities

AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)Highest percentage and number of AV Highest percentage and number of AV G ftG ftGraftsGraftsPatients census Patients census >> 50 patients50 patientsAdministrative support: All intervention Administrative support: All intervention facilities have a stable leadership facilities have a stable leadership pp

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Exclusion CriteriaExclusion CriteriaExclusion CriteriaExclusion Criteria

Patient census < 50 patientsPatient census < 50 patientsPatient census < 50 patientsPatient census < 50 patientsFacilities already included in another QIWP Facilities already included in another QIWP

j t ith th N t kj t ith th N t kproject with the Networkproject with the Network

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ENVIRONMENTAL SCANENVIRONMENTAL SCANENVIRONMENTAL SCAN ENVIRONMENTAL SCAN RESULTSRESULTS

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600

Number of AV Grafts within the AVG Conversion Project Facilities

500

300

400

fts

200

300

Tot

al #

AV

Gra

f

100

0

Upper Arm Graft Lower Arm Graft Leg Graft Other Graft Total # of Grafts

22# Of specified AVG # Of Grafts that have clotted at least once since created from the specied AVGs

Stenosis Monitoring Method Conducted by AV Graft Conversion Facilities (As of June 30, 2008)

7

5

ies

3

4

Num

ber

of F

acili

t

1

2

0

1

DVP (Dynamic Venous Pressure) Transonics Access Flow Doppler Study

23# Of facilities conducting method

Frequency of Stenosis Monitoringcy

4

5

at s

peci

fied

freq

uenc

3

4

acili

ties

Mon

itor

ing

a

1

2

Num

ber

of F

a

0

1

DVP (Dynamic Venous Pressure) Transonics Access Flow Doppler Study

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Every Treatment Monthly When a problem occurs Weekly Quarterly

14

12

8

10

es

6# O

f Fac

ilitie

4

0

2

Patient evaluated for Secondary AVF at the time of intervention for Performs "Sleeves Up" technique

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Patient evaluated for Secondary AVF at the time of intervention for detected stenosis.

Performs Sleeves Up technique

YES NO Did not answer

“Sleeves Up” Exam Followed by Fistulogram

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Planning for a secondary AVF is Planning for a secondary AVF is criticalcritical

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TIMING of Conversion AVG to a TIMING of Conversion AVG to a Secondary AVFSecondary AVF

1st AVG failure triggers evaluation for1st AVG failure triggers evaluation for conversion to a secondary AVF—and a plan is establishedis established…..

2nd AVG failure triggers conversion to an AVF using the fistulogram from the AVG study to evaluate the outflow veins

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Continuum of Vascular Access Care

“ d ” Look, Listen,

FeelAssessment

“Everyday” Every shift,

Every patienty p

Monitoring and Surveillance

DocumentationVascular AccessProgramg

AngioplastyFistulagramInterventions

CQIStatic pressure

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FistulagramThrombectomy

DVPRecirculation

Is the Access Working Properly?Is the Access Working Properly?Is the Access Working Properly?Is the Access Working Properly?

Clearances (URR) greater than 65Clearances (URR) greater than 65Access flow greater than 600Access flow greater than 600Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125ppAble to run prescriptionAble to run prescriptionOther signs and symptoms of access pathologyOther signs and symptoms of access pathologyOther signs and symptoms of access pathologyOther signs and symptoms of access pathology–– RecirculationRecirculation–– DifficultyDifficulty cannulatingcannulating and pain in the accessand pain in the accessDifficulty Difficulty cannulatingcannulating and pain in the accessand pain in the access–– Changes in thrill and bruitChanges in thrill and bruit–– Prolonged bleeding postProlonged bleeding post--dialysisdialysis

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o o ged b eed g posto o ged b eed g post d a ys sd a ys s

Flow Methods in Dialysis AccessFlow Methods in Dialysis Access

Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasound (DDU)Duplex Doppler Ultrasound (DDU)Magnetic Resonance Angiography (MRA)Magnetic Resonance Angiography (MRA)Variable Flow Doppler Ultrasound Variable Flow Doppler Ultrasound ppppUltrasound Dilution (Ultrasound Dilution (TransonicsTransonics): UDT): UDTCritCrit--Line III or Line III or CritCrit--Line IILine IIGlucose Pump InfusionGlucose Pump InfusionUrea DilutionUrea DilutionDifferential Conductivity (Gambro) (HDM)Differential Conductivity (Gambro) (HDM)InIn--line line DialysateDialysate (FMC) (FMC) -- DDDD

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ColorColor--Flow DopplerFlow DopplerColorColor Flow DopplerFlow Doppler

Outpatient radiological procedure doneOutpatient radiological procedure doneOutpatient radiological procedure done Outpatient radiological procedure done quarterlyquarterlyAl ll d d l lt d d lAl ll d d l lt d d lAlso called duplex ultrasound or duplex Also called duplex ultrasound or duplex Doppler studyDoppler studyEvaluates access flow patterns as well as Evaluates access flow patterns as well as areas of access stenosisareas of access stenosis

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Ultrasound Dilution Technique Ultrasound Dilution Technique (Transonics)(Transonics)(Transonics)(Transonics)

Conducted quarterly or as necessaryConducted quarterly or as necessaryConducted quarterly or as necessaryConducted quarterly or as necessaryAKA CritAKA Crit--Line III or CritLine III or Crit--line TKAline TKAVery popular, but not all facilities have Very popular, but not all facilities have transonics ontransonics on--sitesite

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Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)Dynamic Venous Pressure (DVP)

Conducted and recorded at the beginning ofConducted and recorded at the beginning ofConducted and recorded at the beginning of Conducted and recorded at the beginning of each treatment at a each treatment at a specifiedspecified blood flow rate blood flow rate using specified/consistent needle sizeusing specified/consistent needle sizeusing specified/consistent needle sizeusing specified/consistent needle sizeNonNon--standardized dynamic venous pressure standardized dynamic venous pressure

id d t bl it iid d t bl it iare considered as unacceptable monitoring are considered as unacceptable monitoring method by the K/DOQI workgroupmethod by the K/DOQI workgroupAcceptable method for Acceptable method for AVFs only! AVFs only! (KDOQI 2006)(KDOQI 2006)

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Static Venous Pressure (SVP)Static Venous Pressure (SVP)Static Venous Pressure (SVP)Static Venous Pressure (SVP)

Following a unitFollowing a unit--specific procedure forspecific procedure forFollowing a unitFollowing a unit specific procedure for specific procedure for measurement of venous and arterial measurement of venous and arterial measures at zero blood flowmeasures at zero blood flowConducted at least every 2 weeksConducted at least every 2 weeksMeasurements plugged into mathematicalMeasurements plugged into mathematicalMeasurements plugged into mathematical Measurements plugged into mathematical formulaformulaRatio > 0 5 is considered abnormalRatio > 0 5 is considered abnormalRatio > 0.5 is considered abnormalRatio > 0.5 is considered abnormalRefer for fistulagram after 3 abnormal Refer for fistulagram after 3 abnormal readingsreadings

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readings readings

Other MethodsOther MethodsOther MethodsOther Methods

OnOn LineLine Clearance (OLC)Clearance (OLC) conductedconductedOnOn--LineLine--Clearance (OLC) Clearance (OLC) –– conducted conducted quarterly quarterly –– Fresenious technology)Fresenious technology)M ti R A i hM ti R A i hMagnetic Resonance AngiographyMagnetic Resonance Angiography

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Medicare Guidelines for ReferralMedicare Guidelines for ReferralMedicare Guidelines for ReferralMedicare Guidelines for ReferralVenous outflowVenous outflow Arterial inflowArterial inflow–– Elevated venous pressureElevated venous pressure–– Prolonged bleedingProlonged bleeding–– Decreased URRDecreased URR

–– Low pressure in graft when Low pressure in graft when outflow is occludedoutflow is occluded

–– Decreased URRDecreased URR–– Decreased Kt/VDecreased Kt/V–– RecirculationRecirculation

–– Ischemic changes in Ischemic changes in extremityextremity

–– Diminished intraDiminished intra--accessaccess–– Swelling of the extremitySwelling of the extremity–– Pulsatile graftPulsatile graft

Loss of thrillLoss of thrill

Diminished intraDiminished intra access access flow (AKA: arterial pulling flow (AKA: arterial pulling negative)negative)

–– Loss of thrillLoss of thrill–– AneurysmsAneurysms–– Difficult or painful Difficult or painful

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ppcannulationcannulation

Aims to Action: Conducting Aims to Action: Conducting QAPI ili i R idQAPI ili i R id C lC lQAPI utilizing RapidQAPI utilizing Rapid--Cycle Cycle

ImprovementImprovementImprovementImprovement

What is Rapid CycleWhat is Rapid CycleWhat is Rapid Cycle What is Rapid Cycle Improvement?Improvement?

Variant of process improvement that:Variant of process improvement that:p pp p–– relies on existing knowledgerelies on existing knowledge

dramatically shortens discovery processdramatically shortens discovery process–– dramatically shortens discovery processdramatically shortens discovery process–– works on “rapid trial & learn” methodworks on “rapid trial & learn” method–– relies heavily on actionrelies heavily on action

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

result in an improvement?

AiAct Plan

S d D

Aim

Study

Do

RootRoot--Cause ANALYSIS Cause ANALYSIS (Fishbone Diagram)(Fishbone Diagram)

Determine the problem and create aDetermine the problem and create aDetermine the problem and create a Determine the problem and create a problem statement (effect). Write it at the problem statement (effect). Write it at the right center of the chartright center of the chartggBrainstorm the major categories of causes Brainstorm the major categories of causes of the problem. Write them as the main of the problem. Write them as the main ppbranches steaming from the center linebranches steaming from the center lineBrainstorm all possible causes of the Brainstorm all possible causes of the ppproblem. Ask “Why did this happen?” problem. Ask “Why did this happen?” about each cause.about each cause.

RootRoot--Cause ANALYSIS Cause ANALYSIS (Fishbone Diagram (Fishbone Diagram –– cont).cont).

Write subWrite sub causes stemming from thecauses stemming from theWrite subWrite sub--causes stemming from the causes stemming from the category of causescategory of causesC ll t d t t fi tC ll t d t t fi tCollect data to confirm rootCollect data to confirm root--causecauseIf no further causes can be identified, then If no further causes can be identified, then you found the root causes of the problemyou found the root causes of the problem

PlanPlan--DoDo--StudyStudy--ActActPlanPlan DoDo StudyStudy ActActPlanPlan –– Identify Opportunity and plan for changeIdentify Opportunity and plan for changePlan Plan Identify Opportunity and plan for changeIdentify Opportunity and plan for changeDo Do –– Implement the Change on a small scaleImplement the Change on a small scaleStudyStudy Use data to analyze for the change andUse data to analyze for the change andStudy Study –– Use data to analyze for the change and Use data to analyze for the change and determine whether it made a differencedetermine whether it made a differenceActAct –– If the change was successful implement theIf the change was successful implement theAct Act If the change was successful, implement the If the change was successful, implement the plan and continuously monitor results. If the plan and continuously monitor results. If the change did not work change did not work –– start the process again.start the process again.gg p gp g

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

will result in an improvement?

AiAct Plan

St d D

Aim

Study

Do

Developing Your AimDeveloping Your AimDeveloping Your AimDeveloping Your Aim

Write a clear statement of aimWrite a clear statement of aim----make the make the target for improvement unambiguoustarget for improvement unambiguousg p gg p g

Include numeric goalsInclude numeric goalsInclude numeric goalsInclude numeric goals

Set “stretch” aimsSet “stretch” aimsSet stretch aimsSet stretch aims

Focus on issues that are important to yourFocus on issues that are important to yourFocus on issues that are important to your Focus on issues that are important to your organization organization -- choose appropriate goalschoose appropriate goals

Developing Your AimDeveloping Your AimDeveloping Your AimDeveloping Your AimImprovement relies onImprovement relies on intentionintention totoImprovement relies onImprovement relies on intentionintention to to improveimprove

S i l d t & li i ithS i l d t & li i ithSenior leaders set & align aim with Senior leaders set & align aim with strategic goals (involve Medical strategic goals (involve Medical

Director!)Director!)Agreement on aim is criticalAgreement on aim is criticalg ee e o s c cg ee e o s c c

Include a specific time frame for Include a specific time frame for accomplishing your aimaccomplishing your aimaccomplishing your aimaccomplishing your aim

Examples of AimsExamples of AimsExamples of AimsExamples of Aims

100% of all dialysis patients with failing grafts 100% of all dialysis patients with failing grafts will be converted to secondary fistulae by XYZwill be converted to secondary fistulae by XYZwill be converted to secondary fistulae by XYZ will be converted to secondary fistulae by XYZ date date T i th b f ti t tili iT i th b f ti t tili iTo increase the number of patients utilizing To increase the number of patients utilizing AVF as a primary vascular access for AVF as a primary vascular access for hemodial sis b 6 percentage points bet eenhemodial sis b 6 percentage points bet eenhemodialysis by 6 percentage points between hemodialysis by 6 percentage points between June and December 2007June and December 2007

Project Goal:Project Goal:Project Goal:Project Goal:

Decrease in the AVG rate of at least 4Decrease in the AVG rate of at least 4Decrease in the AVG rate of at least 4 Decrease in the AVG rate of at least 4 percentage points within 8 months (October percentage points within 8 months (October 20082008 May 2009) within the group ofMay 2009) within the group of2008 2008 –– May 2009) within the group of May 2009) within the group of participating facilities by converting AVGs participating facilities by converting AVGs to AVFsto AVFsto AVFs.to AVFs.Primary target patients: lower forearm Primary target patients: lower forearm AVG ith hi t f t l t l ttiAVG ith hi t f t l t l ttiAVG with a history of at least one clotting AVG with a history of at least one clotting episode.episode.

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Three Ingredients of an Three Ingredients of an Effective TeamEffective Team

System LeadershipLeadership

Technical Expertise

Day-to-dayLeadershipExpertise Leadership

Establishing Your TeamEstablishing Your Teamgg

Have dayHave day toto day system and technical expertiseday system and technical expertiseHave dayHave day--toto--day, system, and technical expertiseday, system, and technical expertise–– DayDay--toto--day leader gives at least 20% (loses day leader gives at least 20% (loses

sleep)sleep)sleep)sleep)–– System leader can arrange for the resources to System leader can arrange for the resources to

do the workdo the workdo the workdo the work–– Technical experts know the subject matterTechnical experts know the subject matter----

often bedside peopleoften bedside peoplep pp p

Use interdisciplinary team (IDT)Use interdisciplinary team (IDT)

Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe ProgressThe ProgressThe Progress

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Applying The Model: Applying The Model: Ai A iAi A iAims to ActionAims to Action

W k t th i t th (V lW k t th i t th (V lWork together in twos or threes (Vascular Work together in twos or threes (Vascular Access Coordinator is the leader)Access Coordinator is the leader)Identify your projectIdentify your projectIdentify:Identify:yy–– A strong, clear aim statement to guide your A strong, clear aim statement to guide your

improvement work on your projectimprovement work on your project–– An aim that has a numeric, stretch goal includedAn aim that has a numeric, stretch goal included–– How you will form your team using the three How you will form your team using the three

i di f ff ii di f ff iingredients of an effective teamingredients of an effective teamGive feedback to each other in the large Give feedback to each other in the large

U i D f IU i D f IUsing Data for ImprovementUsing Data for Improvement

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

result in an improvement?

Act Plan

S d D

Measure

Study

Do

Measurement GuidelinesMeasurement GuidelinesMeasurement GuidelinesMeasurement Guidelines

The key measures should clarify the aim and The key measures should clarify the aim and make it tangiblemake it tangible

Use outcome and process measures Use outcome and process measures

Integrate measurement into the daily routineIntegrate measurement into the daily routine

U lit ti ll tit ti d tU lit ti ll tit ti d tUse qualitative as well as quantitative dataUse qualitative as well as quantitative data

Seek usefulness, not perfectionSeek usefulness, not perfectionSeek usefulness, not perfectionSeek usefulness, not perfection

Measures:Measures:Measures:Measures:

Process:Process: Outcome:Outcome:Process:Process:Identify patients with Identify patients with lower forearm AVGlower forearm AVG

Outcome:Outcome:Decrease in number of Decrease in number of AVGAVG

Perform “sleeves up “Perform “sleeves up “Refer for vessel mapping Refer for vessel mapping

t d t tit d t ti

Increase in number of Increase in number of AVF (converted from AVF (converted from AVG)AVG)–– support documentation support documentation

re: access problemsre: access problemsObtain Vessel mapping Obtain Vessel mapping

AVG)AVG)

Obta Vesse app gObta Vesse app gresults and actresults and actMonitor newly created Monitor newly created AVF f iAVF f iAVF for maturationAVF for maturation

58

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

will result in an improvement?

Act Plan

St d DSelect

Study

DoChanges

Selecting ChangesSelecting Changesg gg gBlatantly stealBlatantly steal: Use the literature, the : Use the literature, the yyexperience of others, hunches and theories experience of others, hunches and theories (FFBI suggestions)(FFBI suggestions)( gg )( gg )Be strategic: Set priorities based on the aim, Be strategic: Set priorities based on the aim, known problems, and feasibilityknown problems, and feasibilityknown problems, and feasibilityknown problems, and feasibility

Objective of the Test:Objective of the Test:Ch N Ch ?Ch N Ch ?Change or No Change?Change or No Change?

Probably ChangeProbably ChangeProbably ChangeProbably ChangeTestTest

Probably No ChangeProbably No ChangeRecruitRecruit

RedesignRedesignEliminateEliminate

DistributeDistributeContinueContinue

ReduceReduceDeliverDeliver

ContinueContinueExamineExamineDiscussDiscussDeliverDeliver

ImplementImplementDiscussDiscussTeachTeach

Selecting ChangesSelecting ChangesSelecting ChangesSelecting Changes

Test the changes on a small scale Test the changes on a small scale -- “By next Tuesday”“By next Tuesday”C i li i iC i li i i-- Capitalize on curiosityCapitalize on curiosity

-- Have a bias for the “doable”Have a bias for the “doable”

Use change conceptsUse change conceptsSimplifySimplify--SimplifySimplify

--ErrorError--proofproof--Minimize the handMinimize the hand--offsoffsMinimize the handMinimize the hand offsoffs

To Be Considered a Real TestTo Be Considered a Real TestTo Be Considered a Real TestTo Be Considered a Real TestTest was planned including a plan forTest was planned including a plan forTest was planned, including a plan for Test was planned, including a plan for collecting data.collecting data.Pl tt t d d d tPl tt t d d d tPlan was attempted and data was Plan was attempted and data was collected.collected.

i id l d di id l d dTime was set aside to analyze data and Time was set aside to analyze data and study the results.study the results.Action was taken, based on what was Action was taken, based on what was learned.learned.

Two Key PointsTwo Key PointsTwo Key PointsTwo Key Points

Small scale Small scale ≠≠ small change small change Success (or failure) in one PDSA cycle Success (or failure) in one PDSA cycle ≠≠success or failure of the projectsuccess or failure of the projectp jp j

Project Changes and StepsProject Changes and StepsProject Changes and StepsProject Changes and Steps

Identify all patients with lower AVGIdentify all patients with lower AVGIdentify all patients with lower AVG Identify all patients with lower AVG previously clotted at least oncepreviously clotted at least onceP f Sl U d f f thP f Sl U d f f thPerform Sleeves Up exam and refer for the Perform Sleeves Up exam and refer for the vessel mappingvessel mappingBe persistent Be persistent –– educate patients at every educate patients at every opportunityopportunityEngage Medical Director!Engage Medical Director!

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Network Responsibilities:Network Responsibilities:Network Responsibilities:Network Responsibilities:

Project Leader (change agent)Project Leader (change agent)Project Leader (change agent)Project Leader (change agent)Supply the templates for RCA & PDSASupply the templates for RCA & PDSASupply toolkits to facilities & evaluate their Supply toolkits to facilities & evaluate their usefulnessusefulnessProvide monthly feedback (Vascular Access Provide monthly feedback (Vascular Access SIMS reports)SIMS reports)p )p )Conduct monthly phone interviews to Conduct monthly phone interviews to obtain facilityobtain facility--specific dataspecific dataobtain facilityobtain facility specific dataspecific dataFacility site visits for strugglersFacility site visits for strugglers 66

Facilities Responsibilities:Facilities Responsibilities:Facilities Responsibilities:Facilities Responsibilities:Return agreement letter (signed by MD)Return agreement letter (signed by MD)g ( g y )g ( g y )Return scans ASAP (those who did not Return scans ASAP (those who did not return yet)return yet)return yet)return yet)RCA & PDSA due to the Network by RCA & PDSA due to the Network by November 14 2008 (PDSA must be signedNovember 14 2008 (PDSA must be signedNovember 14, 2008 (PDSA must be signed November 14, 2008 (PDSA must be signed by MD)by MD)R i t lkit d id tif t l th t ldR i t lkit d id tif t l th t ldReview toolkit and identify tools that would Review toolkit and identify tools that would work in your facilitywork in your facilityFollow the project timelinesFollow the project timelines

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We are all partners!We are all partners!We are all partners!We are all partners!

Thank you!Thank you!yy

For questions please contact:For questions please contact:Svetlana (Lana) Kacherova, RN, MPH, CPHQSvetlana (Lana) Kacherova, RN, MPH, CPHQQuality Improvement DirectorQuality Improvement DirectorQuality Improvement DirectorQuality Improvement DirectorESRD Network 18ESRD Network 18323323--962962--20202020

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323323 962962 20202020skacherova@nw18.esrd.netskacherova@nw18.esrd.net