Quality Improvement in Nephrology Part 1 – Examining Patient Follow-up Practices

In HiQuiPs by Meherzad KutkyLeave a Comment

The Quality Improvement paradigm has been applied to a wide spectrum of settings and patient populations. There has been an exponential rise in QI publications over the recent decades.1​ In this new HiQuiPs Series we explore the QI paradigm applied to different medical specialties and settings. We start with an example of an outpatient nephrology setting. 

Quality Improvement (QI) in nephrology for patients with kidney disease takes on many different forms depending on the patient’s disease burden and in which setting (inpatient vs. outpatient) they are being followed. In this three part series, we will follow a patient through their journey to illustrate what QI may look like in kidney care.

Dr. P, a nephrologist (kidney specialist) is rounding on the nephrology unit with the medical team. They are seeing Sarah, who has a new diagnosis of kidney failure. Sarah is a 55-year-old female with a history of polycystic kidney disease (PKD). She has just started dialysis urgently in hospital with a tunneled dialysis catheter. When reviewing the case, the team sees that Sarah was found to have abnormal kidney function 10 years ago on a routine health check up with a creatinine of 150 umol/l. At the time, Sarah had been referred to a kidney specialist who made the diagnosis of PKD, but she moved and was lost to follow up. Over the last several weeks, she has been feeling unwell, prompting her to seek medical attention. The new diagnosis of end stage renal disease (ESRD) was discovered. Sarah has other family members with PKD including an older brother who’s kidney function has remained normal and her mother who is on dialysis.

As we think about this case and what to tell Sarah, we go through key targets to optimize her outcomes as she begins the journey to starting her dialysis. Our first thought is ideally she would have been followed by a nephrologist during her entire duration of care as part of an interdisciplinary team. In Ontario, for example, it may involve being followed by a Nephrologist in a Multi-Care Kidney Clinic (MCKC).​2​  Ideally, she would also have had a fistula for vascular access. Additionally given her history of polycystic kidney disease a pre-emptive transplant would have been discussed in MCKC as the best care for her, but we will come back to this topic a bit later. 

There are many considerations to factor in when thinking of a QI project around patient follow-up in an outpatient nephrology clinic. One approach is to evaluate potential areas of improvement by soliciting input through wide stakeholder engagement, and pursuing a root cause analysis. One tool we can also use is the LEAN improvement framework to help streamline the process.

Stakeholder Engagement

A full discussion on stakeholder engagement is outlined in previous HiQuiPs post. An outpatient clinic is a complex setting that involves many individual steps and interactions. Therefore, input from every stage of the process must be considered. It is important to map out the key stakeholders at each stage, and evaluate how they interact with each other, where redundancy may exist and where gaps may be identified. 

Key Stakeholders for nephrology clinic may include: patients, primary care providers in catchment area, nephrologists in the clinic, clinic clerical staff, EMR providers/specialists, clinic nurse/allied health, out laboratory system, MCKC clinic staff (physicians, clerical, allied health etc). 

Identifying these individuals can help assemble a comprehensive core change team  that can share numerous perspectives unique to their roles. Another consideration may be to map out the degree to which each stakeholder needs to be involved. ​3​

Process Mapping

As part of the core team root cause analysis, the team delineates the process from the initial patient physician interaction to the point of contact for follow-up at the MCKC . Each step in the process holds a unique role and potential for problem / improvement. Process Mapping includes five phases from ideation to implementation.​4​

1) Preparation, planning and process identification – including education of core change team on the process mapping tool

2) Data and information gathering 

3) Map generation – reflecting perspectives of different shareholders 

4) Process Analysis – using a flow chart as demonstrated in Figure 1, each step is discussed by the interdisciplinary team of stakeholders and input is given about potential gaps, redundancies, potential for errors, and opportunities for improvement

5) Taking it forward – identifying target areas, using the Lean Framework to implement change

For example, a process map can be a helpful tool to construct the patient journey to  access to the MCKC as illustrated in Figure 1.  

Lean Improvement Framework

Using Lean methodology the team considers areas of targeted improvement, evaluate the processes and information flow in order to:

  • Eliminate steps to reduce delay between them
  • Combine steps to prevent wasteful delay
  • Simplify the system/process where possible
  • Review the sequence of events to support greater efficiency

The goal here is to have the least amount of waste, which in this case can mean decreased the amount of patients lost to follow-up by a specific or measurable goal. In turn, delivering the highest quality and safest patient care. At the center of using this framework is the idea of continuous, sequential improvement. This can be achieved by either removing steps that may be regarded as wasteful in resource or time called non-value added (NVA),  adding steps that are value-added for patients (VA) or reflecting on steps that are necessary for the continuous flow of the system but are not-value added (NVA).​5​ We want to think of this framework in a system focused approach, that more heavily relies on automated and computerized approaches.​6​ After using these framework to analyze the current system, several recommendations were made:

  • Implementation of Nephrologist office EMR reminders of abnormal test results not followed up on. 
  • Use of best practice advisory (BPA) alerts with key diagnoses such as PCKD (in this case for referral to MCKC).
  • EMR alert if patients have not confirmed by email or automated phone message that they received information about a subsequent appointment (with multiple subsequent modalities to establish patient communication. 

The ultimate goal in this scenario is to establish continuous flow, which is complex in the context of healthcare when individuals have multiple competing tasks to perform. The focus in this scenario is to automate certain parts of dealing with high risk results and ensuring follow up. More over to reduce lead times, so that the patient can efficiently move through the value stream. In Sarah’s case, as she was lost to follow up, built-in checks, and efficiency in this system may have made a difference not only in the progression of her disease, but also the steps in her care that are needed for her to start treatment. 

This was an illustration in the outpatient nephrology setting using QI methodology to think through an identified problem. Join us in our next post and we continue to discuss the QI approaches in the nephrology outpatient setting.

Senior Editors: @ahmed-taher; @matthew-hackerteper

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    Mendlovic J, Mimouni F, Arad I, Heiman E. Trends in Health Quality-Related Publications Over the Past Three Decades: Systematic Review. Interact J Med Res. 2022;11(2):e31055. doi:10.2196/31055
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    Silver S, Harel Z, McQuillan R, et al. How to Begin a Quality Improvement Project. Clin J Am Soc Nephrol. 2016;11(5):893-900. doi:10.2215/CJN.11491015
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    Daly A, Teeling S, Ward M, McNamara M, Robinson C. The Use of Lean Six Sigma for Improving Availability of and Access to Emergency Department Data to Facilitate Patient Flow. Int J Environ Res Public Health. 2021;18(21). doi:10.3390/ijerph182111030
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    Al H, Obaid A, Yaseen R, et al. Improving the Workflow Efficiency of An Outpatient Pain Clinic at A Specialized Oncology Center by Implementing Lean Principles. Asia Pac J Oncol Nurs. 2019;6(4):381-388. doi:10.4103/apjon.apjon_21_19
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Meherzad Kutky

Meherzad Kutky is an associate professor and Nephrologist in the Department of Medicine at Trillium Health Partners and a Clinician Scientist with the Institute of Better Health. He completed a Master of Science in Quality Improvement and Patient Safety (University of Toronto). His research focus is on understanding barriers to home dialysis and improving access to chronic kidney disease care locally and provincially. He also serves as QI advisor with the Royal College of Physicians and Surgeons of Canada.

Seychelle Yohanna

Seychelle Yohanna is an associate professor in the Department of Medicine at McMaster University and a transplant nephrologist at St. Joseph’s Healthcare Hamilton. She completed a Master of Science in Quality Improvement and Patient Safety (University of Toronto). Her academic focus is improving access to kidney transplantation and living kidney donation for patients in Ontario with chronic kidney disease. She has a particular interest in removing system barriers to living kidney donation and leads the Hamilton One-Day Living Kidney Donor Assessment Clinic.