fistula first: av fistula maturation project
DESCRIPTION
Fistula First: AV Fistula Maturation Project. Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 October 23, 2008. Special Acknowledgement for Content Contributions: FFBI Leadership Group RMS Lifeline, Inc. DaVita, Inc. - PowerPoint PPT PresentationTRANSCRIPT
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Fistula First: AV Fistula Maturation Project
Svetlana (Lana) Kacherova, QI Director
Lisle Mukai, QI Coordinator
ESRD Network 18
October 23, 2008
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Special Acknowledgement forSpecial Acknowledgement forContent Contributions:Content Contributions:FFBI Leadership GroupFFBI Leadership Group
RMS Lifeline, Inc.RMS Lifeline, Inc.DaVita, Inc.DaVita, Inc.
John 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, CNNQI Director, ESRD Network 16QI Director, ESRD Network 16
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Fistula First Breakthrough Initiative Fistula First Breakthrough Initiative (FFBI) Partners(FFBI) Partners
Dialysis facilitiesDialysis facilities Dialysis patientsDialysis patients NephrologistsNephrologists SurgeonsSurgeons CMSCMS ESRD NetworksESRD Networks State Survey AgenciesState Survey Agencies QIOsQIOs And many more!And many more!
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““Fistula First” GOALFistula First” GOAL
Goal 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 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 patients….40% of prevalent patients….
And in the long-term (2009), a 66% AVF rate in And in the long-term (2009), a 66% AVF rate in prevalent patientsprevalent patients
Additional Goal: Reduce Catheter Use!Additional Goal: Reduce Catheter Use!
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Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)
CMS goal – 66% by June 30, 2009CMS goal – 66% by June 30, 2009 Yearly Network 18 goal – Yearly Network 18 goal – 55.1 %55.1 % by June by June
30, 200930, 2009 Yearly Network Stretch Goal – Yearly Network Stretch Goal – 56.0%56.0% by by
June 30, 2009June 30, 2009 August 2008 AVF rates: NW 18 – 53.7%August 2008 AVF rates: NW 18 – 53.7% US – 50.7%US – 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 of vascular accessof vascular access
2.2. Timely referral to Timely referral to nephrologistnephrologist
3.3. Early referral to Early referral to surgeon for “AVF surgeon for “AVF Only”Only”
4.4. Surgeon SelectionSurgeon Selection5.5. Full range of Full range of
appropriate surgical appropriate surgical approachesapproaches
6.6. Secondary AVFs in Secondary AVFs in AFG patientsAFG patients
7.7. AVF AVF evaluation/placement evaluation/placement in catheter ptsin catheter pts
8.8. Cannulation trainingCannulation training9.9. Monitoring and Monitoring and
maintenancemaintenance10.10. Continuing EducationContinuing Education11.11. Outcomes feedbackOutcomes feedback
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Improvement in Improvement in Prevalent Prevalent AVF AVF Rates Rates by ESRD Networkby ESRD Network
FFBI AVF goal 66%66%
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FFBI AccomplishmentsFFBI Accomplishments Website Updates Ongoing (fistulafirst.org) Calendar of upcoming vascular meetings
(including Networks) Tab for Patient Education materials (patient and
professionals) New interventionist videos uploaded Country-wide workshop for surgeons • More Cannulation DVD reproduction in the
works FF Provider Resource List and FAQs FF Patient Resource List
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FFBI Accomplishments (cont).FFBI Accomplishments (cont).
Information sheets on Change Concepts #6 & #9 Monitoring and surveillance flowchart (CC#9)
Secondary AVF Protocols (CC#6) Secondary AVF Sleeves Up Exam Checklist Access Managers (CC#6) Additional Buttonhole slide set (sharp needles)
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FFBI Strategies to increase AVF FFBI Strategies to increase AVF rate and reduce catheter rate:rate and reduce catheter rate:
Networks should mount an effort to re- educate and 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 and performanceperformance
Everyone 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: Conversion of existing AVG to AVF, utilizing
outflow vein of graft for AVF where feasible OR:
Exam & Vessel Mapping for alternate options Secondary A-V Fistula Options K/DOQI guideline 29: Every patient should be
evaluated for a secondary fistula after each episode of graft failure
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“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 for conversion to a secondary AVF—and a plan is 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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Proactive strategies to increase Proactive strategies to increase AVF Rate:AVF Rate:
Early Referral to Nephrologist & Surgeon – (Patient education/ vessel preservation/ no PICC lines if GFR<45)
Surgical Evaluation (& Placement) of Permanent Access during initial Hospitalization
Vessel mapping/Optimal vessel selection to Increase successful (usable) AVFs & Reduce non-maturing (FTM) AVFs (post-op exam @ 4 wks)
Monitoring & Timely Intervention for late failure / Aggressive Salvage
Conversion of AVG to secondary AVF (use FFBI protocol)
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Reactive strategies to increase AVF Reactive strategies to increase AVF rates (All HD patients with rates (All HD patients with
Catheters)Catheters) Regardless of prior access, nephrologists
and surgeons evaluate all catheter patients as soon as possible for AVF
Protocol for Catheter Indications & Removal- Early recognition & intervention for non- maturing AVFs (post-op exam @ 4 wks)—use FFBI protocol
Monitoring & Timely Intervention for late failure/ Aggressive salvage
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The non-Maturing AVFThe non-Maturing AVF
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AVF Dysfunction/failure to mature AVF Dysfunction/failure to mature (FTM)(FTM)
> 30% of new AVFs fail to mature(FTM)Can markedly reduce early failure rate and interventions in
AVFs by:
Early referral & CKD program = improved patient & vessel selection/ standardized vessel mapping protocol
Early recognition of FTM AVF by evaluation (Monitoring & Surveillance) at 4 wks. & timely
intervention=high salvage rate (CC# 9)
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“NO FISTULA LEFT BEHIND”
CLINICS NEED TO TRACK NEW AVFs……and TAKE ACTION (Evaluate, Refer, Intervene) on
AVFs that are:
1) not adequately maturing at 4-6 weeks
2) have reached 3 months and still cannot be used for 2-needle dialysis
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V626 QAPI Condition StatementV626 QAPI Condition Statement
The 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 program 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 improvement 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:Quality 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 and Must report problems to Medical Director and
QAPIQAPI Outcome- focused Outcome- focused Process continuous & on-goingProcess continuous & on-going Use community accepted standards as targetsUse community accepted standards as targets Include patient satisfaction, infection control, Include patient satisfaction, infection control,
medical injuries & medication errorsmedical injuries & medication errors Plan/Do/Check/Act: Close the loop!Plan/Do/Check/Act: Close the loop!
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PDCA /PDSA StylePDCA /PDSA Style
PLAN
DOCHECK/STUDY
ACT
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Interdisciplinary Team:Interdisciplinary Team:
Show Me Show Me The ProgressThe Progress
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Performance Measures Performance Measures
(V629) Adequacy Kt/V, URR
(V630) Nutrition Albumin, body weight
(V631) Bone disease PTH, Ca+, Phos
(V632) Anemia Hgb, Ferritin
(V633)Vascular access Fistula, catheter rate
(V634) Medical errors Frequency of specific errors
V635) Reuse Adverse outcomes
(V636) Pt satisfaction Survey scores
(V637) Infection control Infections, vaccination status
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Monitoring Performance Monitoring Performance ImprovementImprovement
(V638) The facility must:(V638) The facility must: Continuously monitor its performanceContinuously monitor its performance Take actions that result in performance Take actions that result in performance
improvementimprovement Track to assure improvements are sustained over Track to assure improvements are sustained over
timetime
Inclusion Criteria for Inclusion Criteria for Participating FacilitiesParticipating Facilities
AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data) Highest percentage and number of AV Highest percentage and number of AV
Fistulas placed but not used (source: SIMS Fistulas placed but not used (source: SIMS vascular access monthly reports)vascular access monthly reports)
Patients census Patients census >> 50 patients 50 patients Administrative support: All intervention Administrative support: All intervention
facilities have a stable leadership facilities have a stable leadership
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Exclusion CriteriaExclusion Criteria
Patient census < 50 patientsPatient census < 50 patients Facilities already included in another QIWP Facilities already included in another QIWP
project with the Networkproject with the Network
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ENVIRONMENTAL SCAN ENVIRONMENTAL SCAN RESULTSRESULTS
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Top reasons for fistulas not Top reasons for fistulas not maturing:maturing:
Patient does not exercise arm/lack of patient Patient does not exercise arm/lack of patient education on vascular access care education on vascular access care
Need a surgeon with good technique/surgeon Need a surgeon with good technique/surgeon performance performance
Longer maturation time Longer maturation time Patient’s age group (older the patient, less Patient’s age group (older the patient, less
chance of AVF maturing) chance of AVF maturing) Overall patient’s condition Overall patient’s condition
(multi-level)/Multiple medical conditions (multi-level)/Multiple medical conditions 32
TOP RESOURCES/EDUCATION TOP RESOURCES/EDUCATION REQUESTS (for Patients)REQUESTS (for Patients)
Better illustrations of vascular accesses – Better illustrations of vascular accesses – listing CONS only (Spanish)listing CONS only (Spanish)
Educational material on vascular access Educational material on vascular access types and benefits over a catheter (Spanish)types and benefits over a catheter (Spanish)
Handouts for patients about AVF Handouts for patients about AVF maturation (Exercise for arm)maturation (Exercise for arm)
Pre-ESRD classes for patientsPre-ESRD classes for patients Patient education on vascular access carePatient education on vascular access care
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Education Materials: StaffEducation Materials: Staff
In-service on access education In-service on access education Cannulation in-service for primary Cannulation in-service for primary
cannulators for new AVFscannulators for new AVFs Transonic study machineTransonic study machine Staff education on the maturation processStaff education on the maturation process
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Education (cont).Education (cont).
Nephrologists/Surgeons education on Nephrologists/Surgeons education on vascular accessvascular access
Catheter care for SNF staff to prevent Catheter care for SNF staff to prevent infectionsinfections
Need good surgeons in the areaNeed good surgeons in the area Nephrologists need to partner with good Nephrologists need to partner with good
surgeonssurgeons
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Look, Listen,Feel
AngioplastyFistulagram
Thrombectomy
Continuum of Vascular Access Care
Assessment
Monitoring and Surveillance
Interventions
Documentation
“Everyday” Every shift,
Every patient
Vascular AccessProgram
CQIStatic pressure
DVPRecirculation
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Back to the basics:Back to the basics: Physical Assessment Physical Assessment of Vascular Access is critical!!!!of Vascular Access is critical!!!!
Inspection (look)Inspection (look) Auscultation (listen)Auscultation (listen) Palpation (feel)Palpation (feel)
Use all of your senses for assessment and thenUse all of your senses for assessment and thenuse your memory to compare and contrast theuse your memory to compare and contrast the
condition of the access to previous assessmentscondition of the access to previous assessments
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Inspection: Inspection: LookLook– General development- AVFGeneral development- AVF– Skin conditionSkin condition– ?? Aneurysms/ Pseudoaneurysms?? Aneurysms/ Pseudoaneurysms– Skin color of extremities (warm and dry)Skin color of extremities (warm and dry)– Any swelling ( is there symmetry)Any swelling ( is there symmetry)– Any sign of infectionAny sign of infection– Capillary refill < 2-3 seconds, look for ischemic Capillary refill < 2-3 seconds, look for ischemic
spots on finger tipsspots on finger tips
InspectionInspection
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InspectionInspection
RednessRedness DrainageDrainage AbscessAbscess
Skin ColorSkin Color EdemaEdema Small blue Small blue
Purple veinsPurple veins
Hands: cold, painful, Hands: cold, painful, numbnumb
Fingers: discoloredFingers: discoloredInfection
Central or Outflow
Veinstenosis
Steal Syndrome
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AuscultationAuscultation
Auscultation: Auscultation: ListenListen– Quality and amplitude of bruitQuality and amplitude of bruit– Note pitch changes Note pitch changes – Systolic and diastolic are louder on the arterial Systolic and diastolic are louder on the arterial
sideside– Pitch changes at areas of stenosisPitch changes at areas of stenosis– Whistle or cough sound in the accessWhistle or cough sound in the access
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PalpationPalpation
Palpation: Palpation: FeelFeel– Thrill or pulsation Thrill or pulsation – Normally a thrill present at the anatomists site, Normally a thrill present at the anatomists site,
and disappears after you manually occlude the and disappears after you manually occlude the AVFAVF
– If thrill remains = accessory veinsIf thrill remains = accessory veins– The thrill should lessen going to the venous The thrill should lessen going to the venous
limb of the accesslimb of the access– Thrill can be felt at the site of stenosisThrill can be felt at the site of stenosis
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Palpation (cont).Palpation (cont).
Vein DiameterVein Diameter
- Feel the entire length of the AVF- Feel the entire length of the AVF
- Evaluate for needle site selection- Evaluate for needle site selection
- Check for flat spots – you can see a- Check for flat spots – you can see a
stenosis and feel its thrillstenosis and feel its thrill
- Evaluate if new AVF is ready to - Evaluate if new AVF is ready to
cannulatecannulate
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Fistula ExamFistula Exam
Raise the access arm above the heartRaise the access arm above the heart– The fistula should completely collapseThe fistula should completely collapse– Stenosis located at area of engorgementStenosis located at area of engorgement– Evaluate arterial inflowEvaluate arterial inflow
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Is New AVF Mature? Use the KDOQI Is New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s”
6 - 8 week Post OpCheck AVF Maturation
Diameter Greater than
66 mm
Depth below skin Approximately
6 6 mm
Access Blood Flow Greater than
600 600 mL/Min
6 cm of straight segment
“ “ Rule of 6’s Rule of 6’s ””
Vein Vein MUSTMUST Mature Mature PRIORPRIOR to the to the FIRSTFIRST cannulation cannulation
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Is the Access Working Properly?Is the Access Working Properly?
Clearances (URR) greater than 65Clearances (URR) greater than 65 Access flow greater than 600Access flow greater than 600 Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125 Able to run prescriptionAble to run prescription Other signs and symptoms of access pathologyOther signs and symptoms of access pathology
– RecirculationRecirculation– Difficulty cannulating and pain in the accessDifficulty cannulating and pain in the access– Changes in thrill and bruitChanges in thrill and bruit– Prolonged bleeding post-dialysisProlonged bleeding post-dialysis
Aims to Action: Conducting Aims to Action: Conducting QAPI utilizing Rapid-Cycle QAPI utilizing Rapid-Cycle
ImprovementImprovement
What is Rapid Cycle What is Rapid Cycle Improvement?Improvement?
Variant of process improvement that:Variant of process improvement that:– relies on existing knowledgerelies on existing knowledge– 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 Improvement
What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
Act Plan
Study
Do
Aim
Root-Cause ANALYSIS Root-Cause ANALYSIS (Fishbone Diagram)(Fishbone Diagram)
Determine 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 chart
Brainstorm 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 branches steaming from the center linebranches steaming from the center line
Brainstorm all possible causes of the Brainstorm all possible causes of the problem. Ask “Why did this happen?” problem. Ask “Why did this happen?” about each cause.about each cause.
Root-Cause ANALYSIS Root-Cause ANALYSIS (Fishbone Diagram – cont).(Fishbone Diagram – cont).
Write sub-causes stemming from the Write sub-causes stemming from the category of causescategory of causes
Collect data to confirm root-causeCollect data to confirm root-cause If 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
Plan-Do-Study-ActPlan-Do-Study-Act
Plan Plan – Identify Opportunity and plan for change– Identify Opportunity and plan for change Do Do – Implement the Change on a small scale– Implement the Change on a small scale Study –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 difference Act 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 – start the process again.change did not work – start the process again.
Model for ImprovementModel for Improvement
What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
Act Plan
Study
Do
Aim
Developing Your AimDeveloping Your Aim
Write a clear statement of aim--make the Write a clear statement of aim--make the target for improvement unambiguoustarget for improvement unambiguous
Include numeric goalsInclude numeric goals
Set “stretch” aimsSet “stretch” aims
Focus on issues that are important to your Focus on issues that are important to your organization - choose appropriate goalsorganization - choose appropriate goals
Developing Your AimDeveloping Your Aim Improvement relies onImprovement relies on intentionintention to to
improveimprove Senior 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 critical Include a specific time frame for Include a specific time frame for
accomplishing your aimaccomplishing your aim
Examples of AimsExamples of Aims
70% of all dialysis patients with AVFs created 70% of all dialysis patients with AVFs created after April 2008 will be functional by January after April 2008 will be functional by January 20092009
To 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 hemodialysis by 6 percentage points between hemodialysis by 6 percentage points between October 2008 and May 2009October 2008 and May 2009
Project Goal:Project Goal:
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To decrease the number of AVFs “placed To decrease the number of AVFs “placed but not used” by 20% between October but not used” by 20% between October 2008 and May 2009 within the group of 2008 and May 2009 within the group of participating facilities (N=13)participating facilities (N=13)
Based on the responses from 13 facilities Based on the responses from 13 facilities the total number of AVF’s “placed but not the total number of AVF’s “placed but not used” was 215.used” was 215.
Need to identify target patients with AVFs Need to identify target patients with AVFs created after April 2008 to establish a created after April 2008 to establish a baseline baseline
Target Patients:Target Patients:
Every facility should identify target patients Every facility should identify target patients with fistulas created after April 2008with fistulas created after April 2008
AVFs created before April 2008 should not AVFs created before April 2008 should not be considered as “awaiting maturation” and be considered as “awaiting maturation” and these patients should have a new vascular these patients should have a new vascular access plan createdaccess plan created
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Technical Expertise
Day-to-dayLeadership
System Leadership
Three Ingredients of an Three Ingredients of an Effective TeamEffective Team
Establishing Your TeamEstablishing Your Team
Have day-to-day, system, and technical expertiseHave day-to-day, system, and technical expertise– Day-to-day leader gives at least 20% (loses Day-to-day leader gives at least 20% (loses
sleep)sleep)– System leader can arrange for the resources to System leader can arrange for the resources to
do the workdo the work– Technical experts know the subject matter--Technical experts know the subject matter--
often bedside peopleoften bedside people
Use interdisciplinary team (IDT)Use interdisciplinary team (IDT)
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Interdisciplinary Team:Interdisciplinary Team:
Show Me Show Me The ProgressThe Progress
Using Data for ImprovementUsing Data for Improvement
Model for ImprovementModel for Improvement
What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
Act Plan
Study
Do
Measure
Measurement 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
Use qualitative as well as quantitative dataUse qualitative as well as quantitative data
Seek usefulness, not perfectionSeek usefulness, not perfection
Measures:Measures:
Process:Process: Identify patients with Identify patients with
AVFs that were placed AVFs that were placed after April 2008 but not after April 2008 but not used yet.used yet.
Vascular access Vascular access assessment assessment
Cannulation LogCannulation Log P-t referral logsP-t referral logs Monitor newly created Monitor newly created
AVF for maturationAVF for maturation
Outcome:Outcome: Decrease in number of Decrease in number of
AVF “placed but not AVF “placed but not used”used”
Increase in number of Increase in number of functional AVFsfunctional AVFs
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Model for ImprovementModel for Improvement
What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
Act Plan
Study
Do Select Changes
Selecting ChangesSelecting Changes Blatantly stealBlatantly steal: Use the literature, the : Use the literature, the
experience of others, hunches and theories experience of others, hunches and theories (FFBI suggestions)(FFBI suggestions)
Be strategic: Set priorities based on the aim, Be strategic: Set priorities based on the aim, known problems, and feasibilityknown problems, and feasibility
Objective of the Test:Objective of the Test:Change or No Change?Change or No Change?
Probably ChangeProbably Change
TestTest
RedesignRedesign
EliminateEliminate
ReduceReduce
DeliverDeliver
ImplementImplement
Probably No ChangeProbably No ChangeRecruitRecruitDistributeDistributeContinueContinueExamineExamineDiscussDiscussTeachTeach
Selecting ChangesSelecting Changes Test the changes on a small scale Test the changes on a small scale
- “By next Tuesday”- “By next Tuesday” - Capitalize on curiosity- Capitalize on curiosity - Have a bias for the “doable”- Have a bias for the “doable”
Use change conceptsUse change concepts-Simplify-Simplify
-Error-proof-Error-proof -Minimize the hand-offs-Minimize the hand-offs
To Be Considered a Real TestTo Be Considered a Real Test Test was planned, including a plan for Test was planned, including a plan for
collecting data.collecting data. Plan was attempted and data was Plan was attempted and data was
collected.collected. Time 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.
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 project
Two Key PointsTwo Key Points
AVF Maturation Project:AVF Maturation Project:Network Responsibilities:Network Responsibilities:
Project Leader (change agent)Project Leader (change agent) Supply the templates for RCA & PDSASupply the templates for RCA & PDSA Supply toolkits to facilities & evaluate their Supply toolkits to facilities & evaluate their
usefulnessusefulness Provide monthly feedback (Vascular Access Provide monthly feedback (Vascular Access
SIMS reports)SIMS reports) Conduct monthly phone interviews to obtain Conduct monthly phone interviews to obtain
facility-specific datafacility-specific data Facility site visits for strugglersFacility site visits for strugglers
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Facilities Responsibilities:Facilities Responsibilities: Return agreement letter (signed by MD)Return agreement letter (signed by MD) RCA & PDSA due to the Network by RCA & PDSA due to the Network by
November 14, 2008 (PDSA must be signed November 14, 2008 (PDSA must be signed by MD)by MD)
Review toolkit and identify tools that would Review toolkit and identify tools that would work in your facilitywork in your facility
Follow the project timelinesFollow the project timelines
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We are all partners!We are all partners!
Thank you!Thank you!
For questions please contact:For questions please contact:
Svetlana (Lana) Kacherova, RN, MPH, CPHQSvetlana (Lana) Kacherova, RN, MPH, CPHQ
Quality Improvement DirectorQuality Improvement Director
ESRD Network 18ESRD Network 18
323-962-2020323-962-2020
[email protected]@nw18.esrd.net