Quality Improvement Project

Fistula First Late Adopter Project: Group 1

Project Summary

Purpose: To help a selected group of Network 18 facilities (8 facilities) with AVF rates < 40% improve their rates by 6 percentage points during a six (6) month period. The Network will teach and assist facilities to conduct a Root Cause Analysis using the Fishbone Diagram and develop a Continuous Quality Improvement (CQI) plan implementing the Rapid-Cycle process using the PDSA (Plan-Do-Study-Act) model.

Objectives: Each participating facility will improve their AVF rate by 6 percentage points within a six (6) month period.

Methods: · Select facilities to participate in project based on AVF rates. Selected facilities have an AVF rate of < 40%. · Biostatistician analyzed all participating facility data to determine appropriate achievable goal for project · The Network will conduct a WebEx Conference call teaching facilities how to conduct a Root Cause Analysis using the Fishbone Diagram to find out what the obstacles are within their facilities to AVF evaluation and placement. The WebEx will also teach facilities about the Rapid-Cycle Improvement process and developing a CQI plan using the PDSA model. The WebEx will also give the facilities a chance to discuss issues they may be having with other facility representatives and find ideas/solutions to their problems/concerns. · The Network QI staff will send facilities (via e-mail or fax) the documents necessary for the project: 1. Vascular Access Used In Prevalent Patients (SIMS report) 2. Fishbone Diagram Instructions/Example 3. Blank Fishbone Diagram 4. Guidelines For Using the PDSA Process To Create Change 5. Blank Continuous Quality Improvement (CQI) Plan (PDSA form) 6. Copy of WebEx slides 7. Fistula First Successful Strategies Shared by Network 18 Facilities · The facilities are required to conduct a Root Cause Analysis and develop a CQI plan with their vascular access team and submit their documents to the Network by due date requested. · Network QI staff will review and summarize each facilities CQI plan on a Summary Document. The Summary Document will include Network comments and suggestions. · Facility CQI plans and progresses will be reviewed and discussed with the MRB QIWP subcommittee on a monthly basis. · Conference calls with facilities will be held monthly to discuss progress and issues/concerns. · Monthly feedback reports will be distributed to each facility. (SIMS report) · The Network staff will track and trend facilities’ progress. · At the end of the monitoring period, each facility will be required to conduct a self-evaluation to assess success of plan or necessity for revision of plan. · The Network staff will review and summarize the evaluations on the Summary Document and add comments/suggestions. · Final summary will be sent to facilities (via e-mail or fax) after receipt of December 2007 data (SIMS report). Facilities that met their goal will be instructed to continue plan and revise as necessary. Facilities that did not meet their goal and continue to fall below 40% will be reported to the MRB QIWP subcommittee for further actions.

Timeline: q July 2007 – Facilities selected to participate in project based on AVF rate < 40% q July 2007 – Biostatistician analyzed all participating facility data to determine appropriate achievable goal for project. q July 24, 2007 – WebEx Conference Call q July 31, 2007 – Root Cause Analysis & CQI Plan due q July 31, 2007 – Conference Call #1 q August – December 2007 – Implement plan (Baseline: June data) q August 28, 2007 – Conference Call #2 q September 25, 2007– Conference Call #3 q October 18, 2007 – Mid-project assessment sent to facilities (Summary Document - CQI plan) q October 23, 2007 – Conference Call #4 q November 20, 2007 – Conference Call #5 q December 18, 2007 – Conference call #6 q January 22, 2008 – Facility Self-Evaluations due q January 22, 2008 – Send Biostatistician facility data for analysis q January 29, 2008 – Conference Call #7 q March 2008 – Final summary of CQI plan sent to facilities

Summary: Eight (8) facilities were selected to participate in the Late Adopter Project based on their AVF rate. All facilities selected were facilities with < 40% AVF rates. The Network conducted a WebEx Conference to teach facilities how to conduct a Root Cause Analysis and develop a CQI plan implementing the Rapid Cycle Improvement process using the PDSA model. Each facility submitted a Root Cause Analysis and CQI plan. The goal of the project was for each facility to increase their AVF rate by 6 percentage points. The goal was determined based on statistical analysis performed on historical data of all facilities by the Network Biostatistician and approved by the MRB. The plans were reviewed by the Network staff and MRB QIWP subcommittee. The plans were summarized with Network comments/suggestions added and sent to each facility for review. Facilities implemented their plans from August 2007 – December 2007. The baseline data used for the project was June 2007. Each month, conference calls were conducted with the facilities to review each facility’s progress and share issues, concerns, and ideas about vascular access strategies and care. Also, monthly calls with the MRB subcommittee were conducted to report on the progress of the project and issues/concerns that were discussed with the facilities. The monitoring period ended in December 2007. In January 2008, all facilities were requested to perform a self-evaluation or their plan. This was accomplished by completing their original PDSA form. On the last conference call, all facilities shared their experiences and lessons learned with the project. A final CQI summary with Network comment/suggestions were sent to the facilities for review and guidance on continued improvement of their vascular access plan. Project data was submitted to the Biostatistician for final analysis and yielded a result of:

The targeted group of facilities on the average had a 7.73 percentage point increase over the 8-months period. Individual facilities varied from approximately 4.4 to 18.2 percentage points increase over the period. Of eight participating facilities, two facility trends showed slight non-significant increases and six facilities trends showed significant increases. Overall, AVF fates increased significantly (p<0.05) and the target group reached its 6% goal. Therefore, the Network will continue with the targeted facility approach and identify another group of facilities for targeted interventions.

A final report of the project was presented to the MRB during the February 2008 quarterly MRB meeting and the Quarterly Progress Report.

Lessons learned:

Network Lessons: · Coincide WebEx with the baseline date of the project to allow sufficient time for project. · Summarizing the facilities project with Network comments/suggestions allows facilities to consider other areas of concentration or ideas/strategies that they may not have thought of. · During conference calls, do not ask for volunteers to report on their progress – just select individuals. This allows all facilities to contribute to the call. · Frequent follow up with facilities to ensure participation on monthly calls are very time consuming. We need to hold the facility responsible and determine actions for non-excusable absences.

Facility Lessons: (Comments from facility representatives)

· Early referral to vascular surgeon by nephrologist was key in obtaining our goal. · Facility had internal misrepresentations of vascular access rates. Data had to be extracted a certain way so that it calculated the numbers correctly. · Facility now has a surgeon placing AVFs. He has blocked off 1 day a week for access placement. · Facility admitting new patients with at least appointments for evaluations already scheduled. · Facility persistent with nephrologist to refer patients for evaluation if one is not scheduled upon admission. · Facility insistent that patients with no insurance or transportation while in the hospital have a permanent vascular access placed. · Patients being sent to Vascular Access Center for catheter replacement with AVFs. · Social Worker works very hard to find ways to help patients with transportation to the Vascular Access Center. · Once insurance approved, transportation is established and patient is sent to Vascular Access Center. · Follow-up with vascular access placement is done with the Vascular Access Center. · Nephrologist is now engaged in the Fistula First program. · New patients are sent for vessel mapping at the Vascular Access Center. · Facility re-educates patients who have refused a permanent access. The facility shows them the video obtained from the Network regarding vascular access. · Facility assigned a Vascular Access Manager and was sent to their corporate training for Vascular Access Managers to learn responsibilities and how to use the corporate tools in developing and monitoring a vascular access program for the facility. · Replacing AVGs with AVFs upon failure. · Started referring patients within 1 week of admission for vascular access evaluation and placement. · Ups program helped. · Speaking with nephrologists helped. · Changed pattern of referral to Vascular Access Center. · Making nephrologist understand vascular access care. · Facility is tracking trends for vascular surgeons. They have found a good surgeon in there area. · Facility assigned a specific individual to set appointments. · Facility has been working as a team. · Conducting chair-side counseling with their patients (one-on-one) has proven to be successful. · Facility is now sending their patients to a good surgeon they have found in the area based on success rates. · Started a communication/tracking chart to monitor vascular access status of patients.

Continued Concerns: (Voiced Facility Concerns:) · Insurance issues. · Remotely located facilities not having good surgeons or choices of surgeons in the area. · Some AVGs cannot be converted to AVFs because their veins have become unusable. · Some nephrologists are not cooperating with facilities. · Facility questions the capabilities for their local surgeons.