Fistula First: AV FistulaFistula First: AV Fistula Maturation Projectj

S tl (L ) K h QI Di tSvetlana (Lana) Kacherova, QI DirectorLisle Mukai, QI Coordinator

ESRD Network 18

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ESRD Network 18October 23, 2008

Special Acknowledgement forSpecial Acknowledgement forContent Contributions:Content Contributions:FFBI Leadership GroupFFBI Leadership Group

RMS Lif li IRMS Lif li IRMS Lifeline, Inc.RMS Lifeline, Inc.DaVita, Inc.DaVita, Inc.

John White RN ManagerJohn White RN ManagerJohn 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, CNNi ki k

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QI Director, ESRD Network 16QI Director, ESRD Network 16

Fistula First Breakthrough Initiative Fistula First Breakthrough Initiative (FFBI) Partners(FFBI) Partners(FFBI) Partners(FFBI) Partners

Di l i f ili iDi l i f ili iDialysis facilitiesDialysis facilitiesDialysis patientsDialysis patientsN h l i tN h l i tNephrologistsNephrologistsSurgeonsSurgeonsCMSCMSCMSCMSESRD NetworksESRD NetworksState Survey AgenciesState Survey AgenciesState Survey AgenciesState Survey AgenciesQIOsQIOsAnd many more!And many more!

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And many more!And many more!

“Fistula First” GOAL“Fistula First” GOAL

Goal is to maximize autogenous AVFGoal is to maximize autogenous AVFGoal 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 initialTo achieve in the shorter term (2006) the initialTo 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 patients40% of prevalent patients40% of prevalent patients….40% of prevalent patients….

And in the longAnd in the long--term (2009), a 66% AVF rate in term (2009), a 66% AVF rate in l t ti tl t ti tprevalent patientsprevalent patients

Additional Goal: Reduce Catheter Use!Additional Goal: Reduce Catheter Use!4

Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)

CMS goalCMS goal –– 66% by June 30 200966% by June 30 2009CMS goal CMS goal 66% by June 30, 200966% by June 30, 2009Yearly Network 18 goal Yearly Network 18 goal –– 55.1 %55.1 % by June by June 30 200930 200930, 200930, 2009Yearly Network Stretch Goal Yearly Network Stretch Goal –– 56.0%56.0% by by June 30 2009June 30 2009June 30, 2009June 30, 2009August 2008 AVF rates: NW 18 August 2008 AVF rates: NW 18 –– 53.7%53.7%

USUS 50 7%50 7%US US –– 50.7%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 6.6. Secondary AVFs in Secondary AVFs in of vascular accessof vascular access

2.2. Timely referral to Timely referral to nephrologistnephrologist

AFG patientsAFG patients7.7. AVF AVF

evaluation/placementevaluation/placementnephrologistnephrologist3.3. Early referral to Early referral to

surgeon for “AVFsurgeon for “AVF

evaluation/placement evaluation/placement in catheter ptsin catheter pts

8.8. Cannulation trainingCannulation trainingsurgeon for AVF surgeon for AVF Only”Only”

4.4. Surgeon SelectionSurgeon Selection

8.8. Cannulation trainingCannulation training9.9. Monitoring and Monitoring and

maintenancemaintenance5.5. Full range of Full range of

appropriate surgical appropriate surgical approachesapproaches

10.10. Continuing EducationContinuing Education11.11. Outcomes feedbackOutcomes feedback

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approachesapproaches

Improvement in Improvement in Prevalent Prevalent AVF AVF

70 0%

Rates Rates by ESRD Networkby ESRD NetworkFFBI AVF goal 66%66%

50.0%

60.0%

70.0%

as

g

30.0%

40.0%

rcen

t Fist

ula

10.0%

20.0%Per

0.0%5 8 13 11 6 9 10 14 3 4 12 US 7 18 17 1 2 15 16

ESRD Networks Jan-03 Dec-07

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ESRD Networks Jan-03 Dec-07

FFBI AccomplishmentsFFBI AccomplishmentsFFBI AccomplishmentsFFBI AccomplishmentsWebsite Updates Ongoing (fistulafirst.org)C l d f i l tiCalendar of upcoming vascular meetings (including Networks)Tab for Patient Education materials (patient and (pprofessionals)New interventionist videos uploadedC t id k h fCountry-wide workshop for surgeons • More Cannulation DVD reproduction in the worksFF Provider Resource List and FAQsFF Patient Resource List

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FFBI Accomplishments (cont).FFBI Accomplishments (cont).FFBI Accomplishments (cont).FFBI Accomplishments (cont).

Information sheets on Change Concepts #6Information sheets on Change Concepts #6 & #9 Monitoring and surveillance flowchart (CC#9)(CC#9)Secondary AVF Protocols (CC#6)Secondary AVF Sleeves Up ExamSecondary AVF Sleeves Up Exam Checklist Access Managers (CC#6)Access Managers (CC#6) Additional Buttonhole slide set (sharp needles)

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needles)

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FFBI Strategies to increase AVF FFBI Strategies to increase AVF ggrate and reduce catheter rate:rate and reduce catheter rate:

Networks should mount an effort to re- educate and provide feedback on Change Package, to alland 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 andperformanceperformanceEveryone 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:Re-evaluation of all patients for AVF options:Conversion of existing AVG to AVF, utilizing outflow vein of graft for AVF where feasibleoutflow vein of graft for AVF where feasible OR:Exam & Vessel Mapping for alternate options pp g pSecondary A-V Fistula Options K/DOQI guideline 29: Every patient should beK/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 for1st AVG failure triggers evaluation for conversion to a secondary AVF—and a plan is establishedis 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:AVF Rate:AVF Rate:

Early Referral to Nephrologist & Surgeon –(Patient education/ vessel preservation/ no PICC(Patient education/ vessel preservation/ no PICC lines if GFR<45)Surgical Evaluation (& Placement) of Permanent g ( )Access during initial HospitalizationVessel mapping/Optimal vessel selection to I f l ( bl ) AVF & R dIncrease successful (usable) AVFs & Reduce non-maturing (FTM) AVFs (post-op exam @ 4 wks)Monitoring & Timely Intervention for late failure /Monitoring & Timely Intervention for late failure / Aggressive SalvageConversion of AVG to secondary AVF (use FFBI

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y (protocol)

Reactive strategies to increase AVF Reactive strategies to increase AVF rates (All HD patients withrates (All HD patients withrates (All HD patients with rates (All HD patients with

Catheters)Catheters)Regardless of prior access nephrologistsRegardless of prior access, nephrologists and surgeons evaluate all catheter patients as soon as possible for AVFpProtocol for Catheter Indications & Removal- Early recognition & intervention y gfor non- maturing AVFs (post-op exam @ 4 wks)—use FFBI protocolMonitoring & Timely Intervention for late failure/ Aggressive salvage

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The nonThe non--Maturing AVFMaturing AVFThe nonThe non Maturing AVFMaturing 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)> 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 protocolprotocolEarly recognition of FTM AVF by evaluation (Monitoring & Surveillance) at 4 wks & timely(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……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 dialysis2 needle dialysis

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V626 QAPI Condition StatementV626 QAPI Condition StatementQQ

The dialysis facility must develop implementThe dialysis facility must develop implementThe 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 q y p pq y p pprogram 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 i t d f i ti t d f i timprovement 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:Q lit A t d P fQ lit A t d P fQuality 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 andMust report problems to Medical Director andMust report problems to Medical Director and Must report problems to Medical Director and QAPIQAPIOutcomeOutcome-- focusedfocusedOutcomeOutcome focused focused Process continuous & onProcess continuous & on--goinggoingUse community accepted standards as targetsUse community accepted standards as targetsUse community accepted standards as targetsUse community accepted standards as targetsInclude patient satisfaction, infection control, Include patient satisfaction, infection control, medical injuries & medication errorsmedical injuries & medication errors

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medical injuries & medication errorsmedical injuries & medication errorsPlan/Do/Check/Act: Close the loop!Plan/Do/Check/Act: Close the loop!

PDCA /PDSA StylePDCA /PDSA StylePDCA /PDSA StylePDCA /PDSA Style

PLANACT

DOCHECK/S Y/STUDY

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Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe ProgressThe ProgressThe Progress

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Performance Measures Performance Measures

(V629) Adequacy Kt/V URR(V629) Adequacy Kt/V, URR

(V630) Nutrition Albumin, body weight

(V631) Bone disease PTH Ca+ Phos(V631) Bone disease PTH, Ca+, Phos

(V632) Anemia Hgb, Ferritin

(V633)V l Fi t l th t t(V633)Vascular access Fistula, catheter rate

(V634) Medical errors Frequency of specific errors

V635) Reuse Adverse outcomes

(V636) Pt satisfaction Survey scores

25(V637) Infection control Infections, vaccination status

Monitoring Performance Monitoring Performance IIImprovementImprovement

(V638) The facility must:(V638) The facility must:(V638) The facility must:(V638) The facility must:Continuously monitor its performanceContinuously monitor its performanceTake actions that result in performanceTake actions that result in performanceTake actions that result in performance Take actions that result in performance improvementimprovementTrack to assure improvements are sustained overTrack to assure improvements are sustained overTrack to assure improvements are sustained over Track to assure improvements are sustained over timetime

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Inclusion Criteria for Inclusion Criteria for Participating FacilitiesParticipating Facilities

AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data)Highest percentage and number of AV Highest percentage and number of AV Fi t l l d b t t d ( SIMSFi t l l d b t t d ( SIMSFistulas 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 patients50 patientsAdministrative support: All intervention Administrative support: All intervention ppppfacilities have a stable leadership facilities have a stable leadership

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Exclusion CriteriaExclusion CriteriaExclusion CriteriaExclusion Criteria

Patient census < 50 patientsPatient census < 50 patientsPatient census < 50 patientsPatient census < 50 patientsFacilities already included in another QIWP Facilities already included in another QIWP

j t ith th N t kj t ith th N t kproject with the Networkproject with the Network

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ENVIRONMENTAL SCANENVIRONMENTAL SCANENVIRONMENTAL SCAN ENVIRONMENTAL SCAN RESULTSRESULTS

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AVF Placed vs. Used(Data: SIMS April 2008)

250

(Data: SIMS April 2008)

191

166

135

104103100

150

Num

ber

Of A

VFs

37

67

8085

46 46

66

82 8477

52

67 70

33

5359

65

84

60

18

33 30

A B C D E F G H I J K L M

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Facilities

# AVF Placed 04/08 # AVF Used 04/08

Percentage Of Vascular Accesses(Total of AVF Maturation Project Facilities - Based on Internal Facility Data)

56

60

45.8

40

50

ses

30

40

ge o

f Vas

cula

r A

cces

s

20

Perc

enta

g

10

31

0

AVFs Placed (Used or Not) AVFs In Use AVF Maturing Catheters In Use AVGs In Use

Top reasons for fistulas not Top reasons for fistulas not maturing:maturing:

Patient does not exercise arm/lack of patientPatient does not exercise arm/lack of patientPatient 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 N d ith dN d ith dNeed a surgeon with good Need a surgeon with good technique/surgeon performance technique/surgeon performance Longer maturation time Longer maturation time Patient’s age group (older the patient, less Patient’s age group (older the patient, less g g p ( pg g p ( pchance of AVF maturing) chance of AVF maturing) Overall patient’s condition (multiOverall patient’s condition (multi--Overall patient s condition (multiOverall patient s condition (multilevel)/Multiple medical conditions level)/Multiple medical conditions 32

TOP RESOURCES/EDUCATION TOP RESOURCES/EDUCATION REQUESTS (for Patients)REQUESTS (for Patients)REQUESTS (for Patients)REQUESTS (for Patients)

Better illustrations of vascular accessesBetter illustrations of vascular accessesBetter illustrations of vascular accesses Better illustrations of vascular accesses ––listing CONS only (Spanish)listing CONS only (Spanish)Ed ti l t i l lEd ti l t i l lEducational 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)PrePre--ESRD classes for patientsESRD classes for patientsPatient education on vascular access carePatient education on vascular access carePatient education on vascular access carePatient education on vascular access care

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Education Materials: StaffEducation Materials: Staff

InIn service on access educationservice on access educationInIn--service on access education service on access education Cannulation inCannulation in--service for primary service for primary

l tl t f AVFf AVFcannulatorscannulators for new AVFsfor new AVFsTransonic study machineTransonic study machineStaff education on the maturation processStaff education on the maturation process

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Education (cont).Education (cont).Education (cont).Education (cont).

Nephrologists/Surgeons education onNephrologists/Surgeons education onNephrologists/Surgeons education on Nephrologists/Surgeons education on vascular accessvascular accessC th t f SNF t ff t tC th t f SNF t ff t tCatheter care for SNF staff to prevent Catheter care for SNF staff to prevent infectionsinfectionsNeed good surgeons in the areaNeed good surgeons in the areaNephrologists need to partner with good Nephrologists need to partner with good p g p gp g p gsurgeonssurgeons

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Continuum of Vascular Access Care

“ d ” Look, Listen,

FeelAssessment

“Everyday” Every shift,

Every patienty p

Monitoring and Surveillance

DocumentationVascular AccessProgramg

AngioplastyFistulagramInterventions

CQIStatic pressure

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FistulagramThrombectomy

DVPRecirculation

Back to the basics:Back to the basics: Physical Assessment Physical Assessment of Vascular Access is critical!!!!of Vascular Access is critical!!!!of Vascular Access is critical!!!!of Vascular Access is critical!!!!

Inspection (look)Inspection (look)p ( )p ( )Auscultation (listen)Auscultation (listen)Palpation (feel)Palpation (feel)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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InspectionInspectionInspection: Inspection: LookLook–– General developmentGeneral development-- AVFAVF

pp

pp–– 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)

A i f i f tiA i f i f ti–– Any sign of infectionAny sign of infection–– Capillary refill < 2Capillary refill < 2--3 seconds, look for ischemic 3 seconds, look for ischemic

spots on finger tipsspots on finger tipsp g pp g p

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InspectionInspectionInspectionInspection

RednessRedness Hands: cold painfulHands: cold painfulRednessRednessDrainageDrainageAbscessAbscess

Hands: cold, painful, Hands: cold, painful, numbnumbFingers: discoloredFingers: discolored

InfectionAbscessAbscess

Skin ColorSkin Color

Fingers: discoloredFingers: discolored

C t lSkin ColorSkin ColorEdemaEdemaS ll blS ll bl

Central or Outflow

VeinSteal

SyndromeSmall blue Small blue

Purple veinsPurple veinsstenosis

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AuscultationAuscultationAuscultationAuscultationAuscultation: 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 stenosisPitch 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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PalpationPalpationPalpationPalpationPalpation: Palpation: FeelFeelpp–– Thrill or pulsation Thrill or pulsation –– Normally a thrill present at the anatomists site, Normally a thrill present at the anatomists site,

d di ft ll l d thd di ft ll l d thand disappears after you manually occlude the and disappears after you manually occlude the AVFAVF

–– If thrill remains = accessory veinsIf thrill remains = accessory veinsyy–– The thrill should lessen going to the venous The thrill should lessen going to the venous

limb of the accesslimb of the accessTh ill b f lt t th it f t iTh ill b f lt t th it f t i–– 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)Palpation (cont).Palpation (cont).

Vein DiameterVein DiameterVein DiameterVein Diameter-- Feel the entire length of the AVFFeel the entire length of the AVF

Evaluate for needle site selectionEvaluate for needle site selection-- Evaluate for needle site selectionEvaluate for needle site selection-- Check for flat spots Check for flat spots –– you can see ayou can see a

stenosis and feel its thrillstenosis and feel its thrillstenosis and feel its thrillstenosis and feel its thrill-- Evaluate if new AVF is ready to Evaluate if new AVF is ready to

l tl tcannulatecannulate

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Fistula ExamFistula ExamFistula ExamFistula ExamRaise 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 engorgementg gg g–– 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”Vein Vein MUSTMUST Mature Mature PRIORPRIOR to the to the FIRSTFIRST cannulationcannulation

6 6 - 8 week Post OpCheck AVF Maturation

6 cm of straight segment

Depth below skin Approximately

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Access Blood FlowGreater than600600

“ Rule of 6’s “ Rule of 6’s ””

Diameter

6 6 mm 600 600 mL/Min

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Diameter Greater than

66 mm

Is the Access Working Properly?Is the Access Working Properly?Is the Access Working Properly?Is the Access Working Properly?

Clearances (URR) greater than 65Clearances (URR) greater than 65Access flow greater than 600Access flow greater than 600Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125ppAble to run prescriptionAble to run prescriptionOther signs and symptoms of access pathologyOther signs and symptoms of access pathologyOther signs and symptoms of access pathologyOther signs and symptoms of access pathology–– RecirculationRecirculation–– DifficultyDifficulty cannulatingcannulating and pain in the accessand pain in the accessDifficulty Difficulty cannulatingcannulating and pain in the accessand pain in the access–– Changes in thrill and bruitChanges in thrill and bruit–– Prolonged bleeding postProlonged bleeding post--dialysisdialysis

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o o ged b eed g posto o ged b eed g post d a ys sd a ys s

Aims to Action: Conducting Aims to Action: Conducting QAPI ili i R idQAPI ili i R id C lC lQAPI utilizing RapidQAPI utilizing Rapid--Cycle Cycle

ImprovementImprovementImprovementImprovement

What is Rapid CycleWhat is Rapid CycleWhat is Rapid Cycle What is Rapid Cycle Improvement?Improvement?

Variant of process improvement that:Variant of process improvement that:p pp p–– relies on existing knowledgerelies on existing knowledge

dramatically shortens discovery processdramatically shortens discovery process–– 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 ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

result in an improvement?

AiAct Plan

S d D

Aim

Study

Do

RootRoot--Cause ANALYSIS Cause ANALYSIS (Fishbone Diagram)(Fishbone Diagram)

Determine the problem and create aDetermine the problem and create aDetermine 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 chartggBrainstorm 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 ppbranches steaming from the center linebranches steaming from the center lineBrainstorm all possible causes of the Brainstorm all possible causes of the ppproblem. Ask “Why did this happen?” problem. Ask “Why did this happen?” about each cause.about each cause.

RootRoot--Cause ANALYSIS Cause ANALYSIS (Fishbone Diagram (Fishbone Diagram –– cont).cont).

Write subWrite sub causes stemming from thecauses stemming from theWrite subWrite sub--causes stemming from the causes stemming from the category of causescategory of causesC ll t d t t fi tC ll t d t t fi tCollect data to confirm rootCollect data to confirm root--causecauseIf 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

PlanPlan--DoDo--StudyStudy--ActActPlanPlan DoDo StudyStudy ActActPlanPlan –– Identify Opportunity and plan for changeIdentify Opportunity and plan for changePlan Plan Identify Opportunity and plan for changeIdentify Opportunity and plan for changeDo Do –– Implement the Change on a small scaleImplement the Change on a small scaleStudyStudy Use data to analyze for the change andUse data to analyze for the change andStudy 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 differenceActAct –– If the change was successful implement theIf the change was successful implement theAct 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 change did not work –– start the process again.start the process again.gg p gp g

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

will result in an improvement?

AiAct Plan

St d D

Aim

Study

Do

Developing Your AimDeveloping Your AimDeveloping Your AimDeveloping Your Aim

Write a clear statement of aimWrite a clear statement of aim----make the make the target for improvement unambiguoustarget for improvement unambiguousg p gg p g

Include numeric goalsInclude numeric goalsInclude numeric goalsInclude numeric goals

Set “stretch” aimsSet “stretch” aimsSet stretch aimsSet stretch aims

Focus on issues that are important to yourFocus on issues that are important to yourFocus on issues that are important to your Focus on issues that are important to your organization organization -- choose appropriate goalschoose appropriate goals

Developing Your AimDeveloping Your AimDeveloping Your AimDeveloping Your AimImprovement relies onImprovement relies on intentionintention totoImprovement relies onImprovement relies on intentionintention to to improveimprove

S i l d t & li i ithS i l d t & li i ithSenior 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 criticalg ee e o s c cg ee e o s c c

Include a specific time frame for Include a specific time frame for accomplishing your aimaccomplishing your aimaccomplishing your aimaccomplishing your aim

Examples of AimsExamples of AimsExamples 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 Januaryafter April 2008 will be functional by Januaryafter April 2008 will be functional by January after April 2008 will be functional by January 20092009T i th b f ti t tili iT i th b f ti t tili iTo 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 hemodial sis b 6 percentage points bet eenhemodial sis b 6 percentage points bet eenhemodialysis by 6 percentage points between hemodialysis by 6 percentage points between October 2008 and May 2009October 2008 and May 2009

Project Goal:Project Goal:Project Goal:Project Goal:To decrease the number of AVFs “placed To decrease the number of AVFs “placed b t t d” b 20% b t O t bb t t d” b 20% b t O t bbut 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

ti i ti f iliti (N 13)ti i ti f iliti (N 13)participating facilities (N=13)participating facilities (N=13)Based on the responses from 13 facilities Based on the responses from 13 facilities h l b f l d bh l b f l d bthe 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

58baseline baseline

Target Patients:Target Patients:Target Patients:Target Patients:

Every facility should identify target patientsEvery facility should identify target patientsEvery facility should identify target patients Every facility should identify target patients with fistulas created after April 2008with fistulas created after April 2008AVF t d b f A il 2008 h ld tAVF t d b f A il 2008 h ld tAVFs 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 th ti t h ld h lth ti t h ld h lthese patients should have a new vascular these patients should have a new vascular access plan createdaccess plan created

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Three Ingredients of an Three Ingredients of an Effective TeamEffective Team

System LeadershipLeadership

Technical Expertise

Day-to-dayLeadershipExpertise Leadership

Establishing Your TeamEstablishing Your Teamgg

Have dayHave day toto day system and technical expertiseday system and technical expertiseHave dayHave day--toto--day, system, and technical expertiseday, system, and technical expertise–– DayDay--toto--day leader gives at least 20% (loses day leader gives at least 20% (loses

sleep)sleep)sleep)sleep)–– System leader can arrange for the resources to System leader can arrange for the resources to

do the workdo the workdo the workdo the work–– Technical experts know the subject matterTechnical experts know the subject matter----

often bedside peopleoften bedside peoplep pp p

Use interdisciplinary team (IDT)Use interdisciplinary team (IDT)

Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe ProgressThe ProgressThe Progress

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U i D f IU i D f IUsing Data for ImprovementUsing Data for Improvement

Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

result in an improvement?

Act Plan

S d D

Measure

Study

Do

Measurement GuidelinesMeasurement GuidelinesMeasurement 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

U lit ti ll tit ti d tU lit ti ll tit ti d tUse qualitative as well as quantitative dataUse qualitative as well as quantitative data

Seek usefulness, not perfectionSeek usefulness, not perfectionSeek usefulness, not perfectionSeek usefulness, not perfection

Measures:Measures:Measures:Measures:

Process:Process: Outcome:Outcome:Process:Process:Identify patients with Identify patients with AVFs that were placed AVFs that were placed

Outcome:Outcome:Decrease in number of Decrease in number of AVF “placed but not AVF “placed but not

after April 2008 but not after April 2008 but not used yet.used yet.Vascular accessVascular access

used”used”Increase in number of Increase in number of functional AVFsfunctional AVFsVascular access Vascular access

assessment assessment Cannulation LogCannulation Log

functional AVFsfunctional AVFs

PP--t referral logst referral logsMonitor newly created Monitor newly created AVF f iAVF f iAVF for maturationAVF for maturation

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Model for ImprovementModel for ImprovementModel for ImprovementModel for ImprovementWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

p

will result in an improvement?

Act Plan

St d DSelect

Study

DoChanges

Selecting ChangesSelecting Changesg gg gBlatantly stealBlatantly steal: Use the literature, the : Use the literature, the yyexperience of others, hunches and theories experience of others, hunches and theories (FFBI suggestions)(FFBI suggestions)( gg )( gg )Be strategic: Set priorities based on the aim, Be strategic: Set priorities based on the aim, known problems, and feasibilityknown problems, and feasibilityknown problems, and feasibilityknown problems, and feasibility

Objective of the Test:Objective of the Test:Ch N Ch ?Ch N Ch ?Change or No Change?Change or No Change?

Probably ChangeProbably ChangeProbably ChangeProbably ChangeTestTest

Probably No ChangeProbably No ChangeRecruitRecruit

RedesignRedesignEliminateEliminate

DistributeDistributeContinueContinue

ReduceReduceDeliverDeliver

ContinueContinueExamineExamineDiscussDiscussDeliverDeliver

ImplementImplementDiscussDiscussTeachTeach

Selecting ChangesSelecting ChangesSelecting ChangesSelecting Changes

Test the changes on a small scale Test the changes on a small scale -- “By next Tuesday”“By next Tuesday”C i li i iC i li i i-- Capitalize on curiosityCapitalize on curiosity

-- Have a bias for the “doable”Have a bias for the “doable”

Use change conceptsUse change conceptsSimplifySimplify--SimplifySimplify

--ErrorError--proofproof--Minimize the handMinimize the hand--offsoffsMinimize the handMinimize the hand offsoffs

To Be Considered a Real TestTo Be Considered a Real TestTo Be Considered a Real TestTo Be Considered a Real TestTest was planned including a plan forTest was planned including a plan forTest was planned, including a plan for Test was planned, including a plan for collecting data.collecting data.Pl tt t d d d tPl tt t d d d tPlan was attempted and data was Plan was attempted and data was collected.collected.

i id l d di id l d dTime 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.

Two Key PointsTwo Key PointsTwo Key PointsTwo Key Points

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 projectp jp j

AVF Maturation Project:AVF Maturation Project:Network Responsibilities:Network Responsibilities:

Project Leader (change agent)Project Leader (change agent)Project Leader (change agent)Project Leader (change agent)Supply the templates for RCA & PDSASupply the templates for RCA & PDSASupply toolkits to facilities & evaluate their Supply toolkits to facilities & evaluate their usefulnessusefulnessProvide monthly feedback (Vascular Access Provide monthly feedback (Vascular Access SIMS reports)SIMS reports)p )p )Conduct monthly phone interviews to Conduct monthly phone interviews to obtain facilityobtain facility--specific dataspecific dataobtain facilityobtain facility specific dataspecific dataFacility site visits for strugglersFacility site visits for strugglers 74

Facilities Responsibilities:Facilities Responsibilities:Facilities Responsibilities:Facilities Responsibilities:Return agreement letter (signed by MD)Return agreement letter (signed by MD)g ( g y )g ( g y )RCA & PDSA due to the Network by RCA & PDSA due to the Network by November 14, 2008 (PDSA must be signedNovember 14, 2008 (PDSA must be signedNovember 14, 2008 (PDSA must be signed November 14, 2008 (PDSA must be signed by MD)by MD)Review toolkit and identify tools that wouldReview toolkit and identify tools that wouldReview toolkit and identify tools that would Review toolkit and identify tools that would work in your facilitywork in your facilityF ll th j t ti liF ll th j t ti liFollow the project timelinesFollow the project timelines

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We are all partners!We are all partners!We are all partners!We are all partners!

Thank you!Thank you!yy

For questions please contact:For questions please contact:Svetlana (Lana) Kacherova, RN, MPH, CPHQSvetlana (Lana) Kacherova, RN, MPH, CPHQQuality Improvement DirectorQuality Improvement DirectorQuality Improvement DirectorQuality Improvement DirectorESRD Network 18ESRD Network 18323323--962962--20202020

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323323 962962 20202020skacherova@nw18.esrd.netskacherova@nw18.esrd.net