Peritoneal dialysis challenges and solutions for continuous quality improvement

Patients on maintenance dialysis, their interdisciplinary teams (IDTs) and the supporting system should demand high-quality care that strives for continual improvement. Continuous quality improvement (CQI) principles were first used in business and manufacturing sectors more than 60 years ago and only more recently in the healthcare setting. ^1,2 Many national and regional healthcare systems have formal tools to implement and sustain quality improvements in the healthcare environment, including The UK National Health Services Sustainability Model, several tools from the US Institute for Healthcare Improvement and the Sustainability Planner from Ontario, CA. ^{3 –5} Although pockets of maintenance dialysis programs also adopted these principles many decades ago, ⁶ systematic CQI processes did not begin until more recently. Specific to dialysis, the United States adopted CQI principles through its Medicare End-Stage Renal Disease (ESRD) program. This includes a mandated Quality Assessment Performance Improvement (QAPI) program adopted in the Conditions for Coverage in 2008 and a Quality Incentive Program (QIP) adopted in 2012. The former functions as a required real-time mechanism for improvement in individual dialysis facilities in the United States and could be adopted in international environments. The QIP reports data up to 18 months in arrears. This demonstrates that different quality assessment processes may be more or less useful to implement timely change. ^7,8 Patients have seen improvement in some aspects of care from these programs, but the community has occasionally questioned their value, given the variable real-time impact on important outcomes, such as patient mortality and hospitalisation. ^9,10

Unfortunately, many of the parameters that we monitor in these programs place a greater focus on the in-centre versus the home dialysis population. Fewer metrics have been developed for home dialysis patients, fewer studies addressing CQI have been performed in home dialysis settings and fewer patients undergo home dialysis than in-centre haemodialysis in most dialysis facilities. ¹¹ Some facilities are ‘stand-alone’ home dialysis clinics, but without overlying organisational structure to address the home population, even those clinics may not have adequate infrastructure to support a robust CQI process. Also, some national programs, such as the QIP program, contain several quality metrics that do not apply to home dialysis patients, such as semi-annual In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) patient surveys ¹² and in-centre haemodialysis catheter and fistula rates. Some progress has been made, with the creation and validation of a patient survey instrument for those in the home dialysis environment, but this has not been adopted to date as a counterpart to the ICH-CAHPS in the US system. ¹³ For these, and many other reasons, CQI in peritoneal dialysis (PD) may not be a strong focus of dialysis operations. Even if an interdisciplinary home dialysis team wanted to change this focus, they may not find the resources to do so.

With this background, Hamidi and Shabnam provide our kidney community a timely and important guide, entitled ‘Continuous Quality Improvement in Peritoneal Dialysis: Your Questions Answered’. ¹⁴ The authors examine the importance of CQI principles in PD practice, highlighting potential targets for improvement. The authors begin with an evidence-based discussion on the benefits of CQI for PD populations, which can include improvement in quality of care, with better patient outcomes, greater organisational efficiencies and lower costs to the system. Given the strains on healthcare systems internationally, the authors emphasise the important role that targeted CQI can play to maintain end-stage kidney disease (ESKD) patients on PD. This may preserve access to haemodialysis for other ESKD patients who cannot do PD. In turn, such a strategy leads to sustained growth of PD.

Subsequent sections discuss how a program can choose a framework and Quality improvement (QI) targets. The authors discuss known CQI tools that individual dialysis programs can consider, with a focus on performing PDSA (Plan–Do–Study–Act) cycles as a straightforward and familiar mechanism to improve quality. ¹⁵ They caution how to avoid pitfalls in this process by taking the time to find the right project with the right focus area and the right stakeholders, given the high complexity of a dialysis environment.

Lastly, the authors discuss the creation of a ‘QI Culture’ which is a critical variable needed to sustain beneficial change. Successful strategies include regular improvement huddles, visual management tools and formal QI education for team members. These become embedded in the facility’s culture which enables future QI activity. There are few evidence-based resources in the literature that emphasise CQI in PD, so this serves as an important document for the dialysis care team to review, both at the local and organisational level.

After reviewing this CQI guide, the next step for a PD team can include putting its principles into practice. If CQI is a new area of focus, defining terms around quality can help ‘level-set’ the IDT with a common understanding. Quality can be difficult to define. The Institute of Medicine defined quality as ‘The degree that services for individuals & a population increase the likelihood of the desired health outcome, consistent with current professional knowledge’. ¹⁶ More simply, the Agency for Healthcare Research Quality defined quality as ‘The right care for the right patient at the right time’. ¹⁷ Over many years, our home dialysis program at Northwest Kidney Centers has implemented a CQI program with these definitions in mind that focuses first on the patient and program, and in parallel, ensures that the program meets regulatory requirements. As the birthplace of maintenance PD, we take our role to support quality patient care very seriously at Northwest Kidney Centers. ¹⁸ As the Chief Medical Officer, I work with our home dialysis team to champion patient concerns, first and foremost, as we strive to improve outcomes at the individual and organisational level for our patients, some of the most vulnerable in the medical system. ¹⁹

We recognised that looking at the quality of care for all our PD patients throughout the organisation would provide more robust information than reviewing patients at a single centre. Thus, we adopted a ‘hub and spoke’ model for quality review where the PD IDT, including the organisational PD Medical Director and nursing leadership, reviews quality metrics at the beginning of each month for both the whole program and subsets of patients at each individual centre. At subsequent facility QAPI meetings later that month, a PD Team member represents those patients so that PD patients are not an afterthought of the facility CQI process, but rather have an additional ‘wrap around’ layer of attention, as the facility IDT considers action plans. Also, we have developed data analytics with home dialysis dashboards containing monthly trends of patient and treatment numbers, clinical metrics such as infection rates and anaemia measurements, how patients are referred, reasons for outflow and staff case load. This allows us to understand clinical trends, resource utilisation and predict potential needs. We developed patient assessment tools for patients at various time points, including dialysis initiation, following infections and during times of clinical decline. This was done not to deter patients from starting or continuing home treatments, but rather in conjunction with clinical assessments to determine physical, social and emotional needs or barriers that could be addressed.

Probably the most important component of our continuous quality program is the underlying tenet that we focus on patients first. We encourage the team to ask each other questions – ‘What do we need to champion patient needs?’ ‘How can we help current patients thrive and train those who are ready to start PD?’ ‘How can we innovate, to adopt patient-centred tools and work with researchers to design better supports?’ Overtly committing to forward-thinking ‘patient-first’ approach grounds the team in these basic principles.

Our quality program is embedded within our clinical operations function, which enables a rapid organisational response. When changes are recommended, operational teams can assist more effectively with implementation of action plans. For example, the CQI team recommended that we begin monthly reviews of each PD related infection, which the clinical leadership was able to rapidly implement. This action decreased infection rates and improved team dynamics. In addition, the clinical management in the Home Dialysis department meets monthly with executive leadership to ensure that the successes and needs of the PD program are transparent to the entire organisation. This facilitates additional support that enhances CQI.

In summary, many healthcare providers have minimal training in the field of CQI, and yet we are expected to identify areas of concern, carry out action plans, consider our successes and further refine initiatives. Even when providers are trained, this is a challenging task. Applying CQI in a dialysis setting poses a greater challenge, given multiple competing staff priorities, including routine and urgent patient needs. Nonetheless, the importance of CQI cannot be underestimated to improve care for our patients who remain some of the most vulnerable, chronically ill, socioeconomically disadvantaged in the healthcare setting. ^20,21 Our community needs new strategies to improve patient outcomes, and the guide by Hamidi et al. in this edition of PDI serves as one important addition to our toolkit. However, we are still early in creating a framework for home dialysis improvements. We must advocate for additional research support of this critical patient-centred need, as it serves us with opportunity to improve the care of our PD patients.