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C27: CHECKLISTS

&

WORKFLOW

IN

DIALYSIS CARE

Objectives

� Focus on outpatient CKD processes to dramatically decrease catheter use

� Focus on outpatient CKD processes to dramatically decrease hospitalization rate

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Faculty & Disclosures� Richard Gibney, MD Physician, Central Texas Nephrology

Associates

� Mark Rutkowski, MD, Internist, Nephrologist, Kaiser Permanente Regional Quality and Risk Management

� Laura Johnson, MD, Associate Director of Infection Prevention, Henry Ford Health System

� Tuan Le, MD, Director for Nephrology Business, Kaiser Permanente – South Bay

� H. Yeoh, MD, Outpatient CKD and Preservation of Renal Function, Kaiser Permanente, Southern California

This presentation will discuss the use of gentamicin/citrate for antibiotic lock in the prevention of dialysis catheter infections. The presenters do NOT have a significant financial interest or relationship with the manufacturer(s) of any of the products or provider(s) of any services which will be discussed.

Central Texas Nephrology Associates – Waco Area

Dallas

Waco

Austin

Hillsboro

Bellmead

Marlin

RockdaleWaco West

TempleKilleen

Lampasas GreenwayBrazos

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� Our group began our quality improvement journey in 12/06 after meeting Don Berwick at IHI Annual Meeting in Orlando, Florida.

� We learned:

�There are no bad people, but there are bad processes

�We must change to improve patient care and decrease harm

�Change must be ambitious and bold

� On returning home, our group reviewed our quality data and found we were mediocre.

� Our option was change or die.

CULTUREis defined by what you tolerate

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PROPER PREPARATION FOR

RENAL REPLACEMENT THERAPY

OUTPATIENT

IN-CENTER

HEMODIALYSIS

HOME

THERAPYHOSPITAL

TRANSPLANT

“NO ISOLATED SILOS”

PREPARATION FOR DIALYSIS

OLD WAY

HOSPITAL

&

CATHETER

NEW WAYENGAGE CKD PATIENT & FAMILY

IN THE OUTPATIENT CLINIC

GFR 30 – Education (TOPS)

20 – Access

10 – Start DialysisGOAL: 90% Fistulas

5% Catheters

30% Home Rx

50% Outpatient Practice to Outpatient Dialysis

NO HOSPITAL

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78% OF PATIENTS FOLLOWED BY THE NEPHROLOGISTS FOR 6 MONTHS OR LONGER START DIALYSIS WITH A

CATHETER.

THIS CANNOT BE A GOOD PROCESS.

CKD OUTPATIENT

HAD TO RADICALLY CHANGE

IN PROCESS AND WORKFLOW

AND

BEGIN CHECKLIST

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All members of the medical team

(MD, Clinical Manager, RN, Patient Care Technician, Social Worker, Dietitian, etc.)

are wonderful people committed to kind, caring, compassionate care; they do their

best to give the best care possible.

This is not a people problem.

There are no bad people.

But there are bad processes.

Criteria to Track Quality of Renal Replacement Program:

% of patients STARTING DIALYSIS with fistula only

‘08 ‘09 ‘10 7/11Goal: 70% 30% 32% 36% 46%

% of patients starting dialysis with catheter

‘08 ‘09 ‘10 7/11Goal: 0% 70% 67% 64% 54%

% of patients starting outpatient dialysis (no hospitalization)

‘09 ‘10 7/11Goal: 50% 13 % 19% 22%

% of patients starting outpatient directly to Home Therapy

‘09 ‘10 7/11Goal: 30% 15% 16% 32%

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Remember:

FistulasCMSStandard: 66%

Texas: 57%

Fistulas Catheters Gortex Home Therapy

Our goal: 90% 5% 5% 30%

CTNA Presently: 71% 7% 17% 5%

HOME THERAPY

2006 2009 7/2011

1.5% 2.8% 5.1%

Brand new Home Therapy center will open 11/2011

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Training in CQI

� IHI.org

Don Berwick (Holy man, rock star)

� Checklist Manifesto, New Yorker articles

Atul Gawande

� Virginia Mason

Gary Kaplan, MD, CEO Health System, Seattle, Wa

� Practice, practice, practice

� Buttonhole program, ↑ 250 (drive bad cannulation to 0)

Lynda Ball, Chief of Quality, ESRD Northwest Network

� Process, workflow, IHI courses

� ↓ Hospitalization rate, ↓ Mortality

� Highest quality, lowest cost quadrant

Glomerular Filtraton Rate – GRAPH

Patient Name: Precious Do Wrong

Date of Birth: 11/12/1944

Gender: F

Race: W

Lab dates 12/11/07 12/17/07 6/17/08 5/25/10 7/1/10 8/9/10 9/14/10 10/12/10 10/29/10 1/24/11 5/8/11 5/20/11 6/28/11 8/16/11

G F R 43.71 43.70 32.32 25.20 22.99 19.59 16.98 15.75 16.88 12.56 11.88 11.08 11.26 10.63

Age 63.1 63.1 63.6 65.6 65.7 65.8 65.9 66.0 66.0 66.2 66.5 66.6 66.7 66.8

Creatinine 1.1 1.1 1.4 2.0 2.2 2.6 2.8 2.9 2.9 3.7 4.0 4.1 4.1 4.3

BUN 32 32 34 30 28 33 35 41 42 46 58 50 51 44

Albumin 2.8 2.8 2.4 3.2 2.9 2.8 2.9 3.5 3.1 3.8 3 3.3 3

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6/21/2010 30 - EDUCATION

Tour facility & Home Therapy program

Billing notified __________

20 – HomeTherapy referral ____

Home Therapy date seen ______

Nx Stage

Peritoneal Dialysis

Nocturnal

Methodist Transplant referral pre-emptive

Access Placement _______

Dialysis RN “ok” _________

Palliative & Hospice __________

10 – Outpt to Outpt Dialysis _______

Billing notified ________

Social Worker ______

Clip ______

FAMILY

DATE

COMPLETED GFR

DATE

COMPLETED

Glomerular Filtraton Rate - GRAPH

Patient Name: Dudley Do Right

Date of Birth: 7/22/61

Gender: M

Race: W

Lab dates 6/25/08 4/12/11 7/1/11 7/27/11 8/15/11 9/13/11 9/15/11

G F R 61.92 23.67 18.57 17.42 16.00 14.20 9.91

Age 47.0 49.8 50.0 50.0 50.1 50.2 50.2

Creatinine 1.40 3.20 3.70 4.20 4.2 4.9 6.0

BUN 27 45 49 55 57 73 115

Albumin 3.5 3.1 3.1 3.1 2.4

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5/23/2011

5/23/2011

5/23/2011

5/16/2011

5/30/2011

Yes

5/16/2011

7/19/2011

9/6/2011

9/20/2011

9/15/2011

9/15/2011

9/15/2011

5/23/2011

30 - EDUCATION

Tour facility & Home Therapy program

Billing notified Iva

20 – HomeTherapy referral ____

Home Therapy date seen ______

Nx Stage

Peritoneal Dialysis

Nocturnal

Methodist Transplant referral pre-emptive

Access Placement Dr. Settles (AVF) 2nd Stage

Dialysis RN “ok” Merry

Palliative & Hospice __________

10 – Outpt to Outpt Dialysis Greenway

Billing notified Iva

Social Worker Joe Hall

Clip ______

FAMILY

DATE

COMPLETED GFR

DATE

COMPLETED

How do we track people in outpatient clinic to optimize

follow-up:

� Checklist, continuous process & workflow

remodeling

� Phone calls

� Immediate follow-up after TOPS Education

� Call family

� Nephrologist, nurse accountable for access

evaluation every visit

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STUNNING HOME THERAPY CHANGE:

TREATMENT OPTIONS

1. P.D.

2. IN-CENTER NOCTURNAL DIALYSIS

3. NXT STAGE 6 DAYS/WEEK

4. TRANSPLANT

5. TRADITIONAL HOME HEMODIALYSIS

6. IN-CENTER HEMODIALYSIS (LAST RESORT)

TOPS EducationConnie White, RN

Tunesha Wilson, RN

“All I needed was a plan.”

-- CKD Patient

Engage the Patient

We Care

Provide education that permeates patient centered experience.

WELLNESS PROGRAM

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JUST HOW DID WE DO THAT?!

� In 2010 survey of TOPS classes showed

that 50% of the patients choose “HOME

THERAPIES” as treatment of choice.

� As of August 2011 survey of TOPS

classes showed that 60% of the patients

choose “HOME THERAPIES” as treatment

of choice!!!!!

CTNA Dialysis Patient Hospitalization Rate:

June

2009 2010 2011

↓11% ↓15% ↓ 6%

We have changed from a SICKNESS to a WELLNESS program.

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SMR

.7

PROPER PREPARATION FOR

RENAL REPLACEMENT THERAPY

OUTPATIENT

IN-CENTER

HEMODIALYSIS

HOME

THERAPYHOSPITAL

TRANSPLANT

“NO ISOLATED SILOS”

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� Focus and innovation in outpatient practice with these goals:

�70% Start dialysis with functioning fistula

�50% Start dialysis outpatient to outpatient dialysis unit

(No hospital)

�30% Start dialysis as home therapy

� Training in CQI (PROCESS AND WORK FLOW)

� CHECKLIST radically improved practice

� Education should permeate your practice

TAKE HOME MESSAGE

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It is a joyful journey, and when you are frustrated or angry along the way, simply “call your friends and they will sustain and repair your joy,” Don Berwick.