Quality Management

DCI has implemented the structure and process to accomplish this goal. The corporate QM committee, comprised of representatives from DCI clinics, a social worker and a dietitian, meets semi-annually. The QM committee is chaired by Dr. Phillip Zager, who is the Medical Director of the Albuquerque DCI dialysis unit. The QM office located in Albuquerque, New Mexico collects, analyzes and distributes data related to quality management for use by the clinics, QM committee, research and other initiatives as approved through the corporate office. The QM office located at the corporate office in Nashville monitors clinic level quality management programs and works with the individual clinics to improve patient outcomes through education.

The QM program is built around the principles contained in the Joint Commission for Accreditation of Health Care Organizations (JCAHO) modified lO-step model (structure) and Deming’s Total Quality Management model for CQI (process). Specific areas addressed include: identification of patient needs, measurement of quality, setting goals, creating the means for achieving continuous quality improvement and learning from past experiences, evaluating cost-effectiveness, developing and maintaining information systems and databases, and establishing information-driven decision making (Couch, 1991).

Objectives:

1. Develop a system for monitoring quality indicators in order to document quality.
2. Identify clinical practice techniques that result in desirable patient outcomes.
3. Engage all clinics in an ongoing examination of performance.
4. Develop internal standards and goals, while adhering to external benchmarks.

Specific Aims:

1. Optimize patient care and outcomes.
2. Provide safe dialysis and minimize treatment-related complications.
3. Contain costs while maintaining quality care.
4. Obtain documentation to assess therapy and results.
5. Document situations where high quality patient care already exists.
6. Document opportunities for improving quality.
7. Maintain patient, clinic, and staff confidentiality.
8. Document effectiveness by showing improvement in patient care.
9. Utilize data collected to answer new questions.
10. Fulfill regulatory and licensing requirements for QM.

The DCI QM structure and process is evaluated on an ongoing basis. The areas reviewed include team participation (QM Minutes), establishing indicator criteria and goals, and data quality and analysis. The effectiveness of the program is evaluated using benchmarking techniques comparing DCI aggregate data to national benchmarks (NKF Kidney Disease Outcomes Quality Initiative (K/DOQI), CMSIESRD Network Clinical Performance Measures (CPM), and the US Renal Data Systems (USRDS)), assessment of functional status and patient satisfaction.

The facility-specific QM programs monitor clinical indicators including adequacy of dialysis, anemia, nutrition, osteodystrophy, CV risk factors, morbidity and mortality. Technical indicators for water treatment, dialyzer reprocessing and equipment maintenance are monitored and reviewed.

The corporate QM program monitors these quality indicators as individual clinic data and as corporate-wide composite data. Adequacy of dialysis is monitored by tracking prescribed and delivered dialysis dose (spKtN), urea reduction ratio (URR), and hours on dialysis. Nutritional indicators include serum albumin, normalized protein catabolic rate (nPCR), and body mass index (BMI). Anemia is monitored by tracking calculated hematocrit, hemoglobin, iron, ferritin, total iron binding capacity (TIBC), transferrin, % transferrin saturation, and EPO dose. Osteodystrophy indicators include calcium, adjusted calcium (corrected for serum albumin), phosphorus, calcium-phosphorous product, alkaline phosphatase, and parathyroid hormone. Cardio-vascular (CV) risk factor indicators include cholesterol, triglycerides, and pre- and post- dialysis blood pressure (BP) control. The average systolic, diastolic, and mean arterial blood pressures are calculated, and antihypertensive medications are tracked.

Quality indicators followed for peritoneal dialysis patients include laboratory data for adequacy, anemia, nutrition, osteodystrophy, CV risk factors, peritonitis and exit site infection rates, and outcomes. Corporate QM calculates standardized mortality ratios (SMR), and Kaplan-Meier survival curves annually.

Statistical monitoring and feedback are essential components of our QM program. Population- based studies offer many advantages over other forms of statistical monitoring. It allows for examination of variations in medical practice, support for resource planning, identifies and monitors morbidity and mortality levels among populations, and defines targets for patient education.

The QM indicator data is extracted in a uniform manner using the DCI Medical Information System (MIS) report writer program and downloaded quarterly. Data are analyzed using Statistical Analysis System (SAS). Data collected includes the following files: demographic; blood pressure; and laboratory files.

Mortality & Survival Rates: Standardized mortality ratios (SMR) are calculated per USRDS methodology. Mortality information is extracted annually and verified against total deaths reported to HCFA on the ESRD Facility Survey (HCFA 2744), with a copy of the ESRD Death Notification (HCFA 2746) to verify individual deaths.

Product-limited (Kaplan-Meier) survival analyses allow survival comparison in different groups of patients. Survival curves are plotted and a likelihood ratio test is performed for significance testing. Cox proportional hazards models and logistic regression are utilized to assess the effect of discrete and continuous variables on outcomes, e.g. gender, ethnicity, age, modality, blood pressure, and primary diagnosis. Co-Morbidity & Hospitalizations: Co-morbidity is assessed using the Index of Coexistent Disease (ICED). Data collected to calculate hospitalization rates include patient identification, clinic location, admission date, discharge date, discharge diagnosis (lCD), and outcome. Hospitalizations are reported as hospital days per patient year.

Special Studies and Analyses: The composition of data files depends upon selection criteria for a specific study. Files may be merged in any combination to provide the desired information for special studies. The data collection, management and analysis capabilities of the QM program enable DCI to facilitate research in end-stage renal disease. The DCI QM data base is currently being used to support a Patient Outcome Research Team (PORT) directed by Neil Powe, MD, MPH, MBA, at Johns Hopkins University School of Medicine.

Patient functional status is assessed using the Short Form 36 (SF-36) Health Survey. The questionnaire contains 36 items that measure eight dimensions: physical functioning, role limitations due to physical problems; social functioning, bodily pain, general mental health, role limitations due to emotional problems, vitality, and general health perceptions. Results are analyzed and reported quarterly.

The DCI Clinic Report Card patient satisfaction survey is a tool designed to assess the patient’s perception about the care they receive, and to evaluate the interpersonal aspects of patient care. The questionnaire addresses the following issues: patient autonomy; patient education; staff concern, support, and professionalism; scheduling; and overall quality of care and services.

QM Quarterly Reports: To maintain clinic confidentiality, clinics are assigned a random identification number, and data is blinded at the corporate QM committee level. Aggregate data for all DCI facilities are compiled and trended from the individual clinic data, and electronically transmitted to all clinic servers. Quarterly reports provide information on how individual clinics compare to DCI aggregate data for each indicator. Results are reported for 5 _ percentiles, and percent met criteria. The Quarterly Report Table of Contents may be found in Appendix A.

The DCI QM program is constantly evolving to ensure that we continue to provide the highest quality care to our patients. The corporate QM office serves as a resource available to assist clinics in the development, implementation, and improvement of their clinic-specific QM program. We are also available to respond to special requests that may facilitate patient care and clinical research.

References
Couch, J.B. (Ed.) (1991). Health care quality management for the 21st century Venice, FL: American College of Physician Executives.
Lewis, S.L., Campbell, M.A., Becktell, P.J., Cooper, CL., Bonner, P.N., & Hunt, W.C. (1992).
Work stress, burnout, and sense of coherence among dialysis nurses. ANNA Journal 19(6), 545-554.
Meyer, K.B., Espindle, D.M., DeGiacomo, J.M., Jenuleson, C.S., Kurtin, P.S., Allyson, R.D. (1994). Monitoring dialysis patient’s health status. American Journal of Kidney Diseases US Renal Data System, USRDS 2001 Annual Data Report The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.