STRUCTURE & PROCESS
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).
- Develop a system for monitoring quality indicators in order to document quality.
- Identify clinical practice techniques that result in desirable patient outcomes.
- Engage all clinics in an ongoing examination of performance.
- Develop internal standards and goals, while adhering to external benchmarks.
- Optimize patient care and outcomes.
- Provide safe dialysis and minimize treatment-related complications.
- Contain costs while maintaining quality care.
- Obtain documentation to assess therapy and results.
- Document situations where high quality patient care already exists.
- Document opportunities for improving quality.
- Maintain patient, clinic, and staff confidentiality.
- Document effectiveness by showing improvement in patient care.
- Utilize data collected to answer new questions.
- 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.