How Can We Decrease Early Dialysis Initiation? An Interactive Quality Improvement Teaching Case for Health Care Providers and Narrative Review of Quality Improvement Methodology

Abstract

Purpose of review: Quality improvement (QI) initiatives use a team-based approach to problem-solving clinical and health system issues. All QI initiatives require the coordinated efforts of health care professionals and other stakeholders to encourage the provision of evidence-based clinical care. Most clinicians understand the principles of QI but may lack the training necessary to undertake individual projects.

Methods: An educational, nephrology-oriented clinical case was created based on the IDEAL study on timing of dialysis initiation, a prioritized quality indicator in several provinces. The case illustrates how to utilize commonly employed QI methodology and to provide a pragmatic framework for both developing and running a QI project. Core concepts addressed in this review include how to perform a QI chart audit, identification of a quality-of-care problem, engaging stakeholders, and how to conduct a root cause analysis that leads to selection of QI measures and change solutions. Last, plan-do-study-act (PDSA) cycles and interpretation of data using run charts are highlighted.

Sources of information: PubMed and Google scholar were used as sources of published QI methodology.

Key findings: This nephrology-oriented QI case highlights how a core set of QI principles and tools can be used to improve clinical care. This review demonstrates that determining clear goals, utilizing evidence-based guidance to improve timing of dialysis initiation, engaging the appropriate stakeholders, identifying a feasible and measurable change, and tracking if that change leads to improvement are essential components of all QI initiatives. The above framework can be utilized in a variety of clinical areas both within and beyond nephrology-specific care.

Limitations: Considerations regarding QI-specific data analysis were not addressed as they were beyond the scope of this review.

Keywords: advanced chronic kidney disease; dialysis start; education; quality assurance; quality improvement.

Figure 1.

Power vs interest grid.

Figure 2.

The 5 Why’s—Determining the root cause of a clinical problem.

Figure 3.

Example of a Fishbone / Ishikawa diagram considering the reasons why people followed in the multidisciplinary kidney clinic may be starting on dialysis early.

Figure 4.

Example of a Pareto diagram.

Figure 5.

Example of an affinity diagram where change ideas are developed and categorized.

Figure 6.

Example of a design and person-oriented change ideas organized by their effectiveness.

Figure 7.

Example of a PICK chart (possible, implement, challenge, kill).

Figure 8.

Example of a run chart template.

Figure 9.

Example of a run chart identifying change in practice over time. Outliers, or astronomical data points are highlighted. A run chart can be interpreted by counting the number of times the line connecting the data points crosses the median which indicates change in practice over time.

Figure 10.

Run chart showing the percentage of patients starting dialysis early (eGFR >9.5 mL/min/1.73 m)². • Arrow 1: No meaningful change with the first PDSA cycle. • Arrow 2: Trend and shift with the second PDSA cycle. • Arrow 3: Upward trend due to lack of regular review of eGFR prior to starting. • Arrow 4: Trend downward with the 3^rd PDSA cycle.