A. Introduction QI Project Application/Report for Part IV MOC Eligibility 1. Date (this version of the application): 6/9/2014 2. Title of QI project: Improving Chronic Kidney Disease (CKD) Staging 3. Time frame a. At what stage is the project? Design is complete, but not yet initiated Initiated and now underway x Completed (UMHS Part IV program began 1/1/11) b. Time period (1) Date physicians begin participating (may be in design phase): 04/25/2013 (2) End date: x actual 6/02/2014 X expected 05/2014 4. QI project leader [responsible for attesting to the participation of physicians in the project]: a. Name: David Kershaw b. Title: Professor c. Institutional/organizational unit/affiliation: University of Michigan Pediatric Nephrology d. Phone number: 734-232-7690 e. Email address: dkershaw@umich.edu f. Mailing address: C.S. Mott Children s Hospital 12-260B 1540 E. Hospital Drive SPC 4297 Ann Arbor, Michigan 48109-4279 5. What specialties and/or subspecialties are involved in this project? Pediatric Nephrology and Pediatrics (resident) 6. Will the funding and resources for the project come only from internal UMHS sources? XYes, only internal UMHS sources No, funding and/or resources will come in part from sources outside UMHS, which are: The Multi-Specialty Part IV MOC Program requires that projects engage in change efforts over time, including at least three cycles of data collection with feedback to physicians and review of project results. Some projects may have only three cycles while others, particularly those involving rapid cycle improvement, may have several more cycles. The items below are intended to provide some flexibility in describing project methods. If the items do not allow you to reasonably describe the methods of your specific project, please contact the UMHS Part IV MOC Program office. B. Plan 7. General goal 1. Problem/need. What is the gap in quality that resulted in the development of this project? Why is this project being undertaken?
Pediatric patients seen in clinic with CKD often do not have CKD staging or the correct staging on their problem list. In adults egfr is provided by automatic calculations by lab, which facilitates staging. This does not occur in children and manual calculations are required to calculate egfr and CKD stage. This potentially leads to missed CKD diagnosis. This results in both clinical and administrative problems. Clinical: Patients with unrecognized (or incorrectly graded) CKD are at risk for inappropriate/inadequate follow-up, drug dosing complications, and contrast induced nephropathy. Administrative: In addition CKD is an important comorbidity for inpatient facility billing that if not included costs the institution money. b. Project goal. What outcome regarding the problem should result from this project? Patients seen in clinic with CKD will have correct CKD staging in their problem list. 8. Patient population. What patient population does this project address. Patients seen in Pediatric Nephrology Clinics who have 1) creatinine measured or 2) CKD qualifying diagnosis (single kidney, posterior urethral valves etc). 9. Which Institute of Medicine Quality Dimensions are addressed? [Check all that apply.] X Safety Equity Timeliness X Effectiveness X Efficiency X Patient-Centeredness 10. What is the experimental design for the project? X Pre-post comparisons (baseline period plus two or more follow-up measurement periods) Pre-post comparisons with control group Other: 11. Baseline measures of performance: a. What measures of quality are used? If rate or %, what are the denominator and numerator? Population identification. Participants will review the charts of patients seen in Pediatric Nephrology Clinics (during time period assigned) and assess if they have 1) creatinine measured or 2) CKD qualifying diagnosis (single kidney, posterior urethral valves etc). CKD staging criteria. For those with creatinine measured the participant will calculate the estimated glomerular filtration rate and stage the CKD (see chart below). For those less than 18 years old the height based estimated creatinine clearance (egfr=k * Ht/Creat where k= 0.413), For those 18 yo and above MDRD creatinine clearance will be used. If a cystatin C was obtained the clearance will be calculated and recorded.
Measures. We will analyze the data to determine: - Rate of CKD in those with creatinine measured or CKD qualifying diagnosis (# with CKD / Total patients identified per criteria in question 8) - Rate of identification of CKD (# with CKD in problem list/# with CKD identified on review) b. Are the measures nationally endorsed? If not, why were they chosen? The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) has provided evidence-based clinical practice guidelines for all stages of chronic kidney disease (CKD). Inherent in the use of these guidelines is the appropriate recognition and staging of CKD. c. What is the source of data for the measure (e.g., medical records, billings, patient surveys)? Medical records (Michart) d. What methods were used to collect the data (e.g., abstraction, data analyst)? Manual abstraction (by participants) - Each participant will review clinic lists for patients for a 7 day assigned period. Each participant will screen sufficient charts to have 30 charts with creatinine measured or a CKD qualifying diagnosis to capture data listed above. General nephrology charts will be screened first and transplant clinic charts will be examined only if the requisite 30 charts with creatinine were not obtained (to prevent oversampling of transplant patients). e. How reliable are the data being collected for the purpose of this project? It is possible that some patients with CKD/creatinine measurements will not be captured due to Michart lab integrity issues. f. How are data to be analyzed over time, e.g., simple comparison of means, statistical test(s)? Comparison of means since dataset will be small g. To whom are data reported? Participants (faculty, fellows, and in this section the resident). Final summary will be provided to Department Chair. h. For what time period is the sample collected for baseline data? Baseline data will be obtained from patients seen in clinic in February through April 15th 2013. 12. Specific performance objectives
a. What is the overall performance level(s) at baseline? (E.g., for each measure: number of observations or denominator, numerator, percent. Can display in a data table, bar graph, run chart, or other method. Can show here or refer to attachment with data.) Time Period Baseline: 2/1 4/15/13 # Patients Meeting Inclusion Criteria If Included, # with CKD Identified by Criteria If CKD Identified by Criteria, # with CKD in Problem List 158 70 44% (70/158) 18 25% (18/70) The data show a gap in performance that should be addressed. b. Specific aim: What is the target for performance on the measure(s) and the timeframe for achieving the target? All patients with CKD stage > II or CKD with anatomic or functional CKD I (ie single kidney, Fabry disease) will be identified on problem list with correct stage of CKD. c. How were the performance targets determined, e.g., regional or national benchmarks? Per DOQI benchmarks all patients with CKD should be identified and care should be directed in part by CKD stage. In addition as we migrate to EPIC inpatient accurate problem list inclusion of CKD will enhance billing efficiency. 13. Data review and identifying underlying (root) causes. a. Who will be/was involved in reviewing the baseline data, identifying underlying (root) causes of the problem(s), and considering possible interventions ( countermeasures ) to address the causes? Briefly describe who is involved, how (e.g., in a meeting of clinic staff), and when. Faculty, fellow and one resident participant met on 6/7/2013 to analyze and collate results. Data for each provider and stage of CKD was analyzed to identify variances and were compared to group averages. The group worked to identify processes that may have led to better (or worse) outcomes in different groups. b. What are the primary underlying/root causes for the problem(s) that the project can address? (Causes may be aspects of people, processes, information infrastructure, equipment, environment, etc. List each primary cause separately. How the intervention(s) address each primary underlying cause will be explained in #14.c.) 1) Lack of use of problem list some users had diagnosis listed in note (prose) but not in Michart - this does not assist in the care of these patients in other venues (radiology, emergency room, etc). 2) Lack of clear definition of CKD (anatomic/functional CKD) 3) Different egfr calculations used multiple available 4) Data collection tool not adequate. C. Do 14. Intervention(s). a. Describe the interventions implemented as part of the project. Feedback concerning actual performance occurred as part of data review.
Educated providers on the need for functional problem list for billing, patient safety, efficient care, and research Clarified that all patients with single kidney, posterior urethral valves, autosomal dominant polycystic kidney disease, Fabry disease, autosomal recessive kidney disease will be listed as having CKD regardless of kidney function assessment (CKD I if egfr normal) Standardization for the use of 0.413 constant for calculation of egfr Placards were placed in front of the computers of the 8 th floor clinic work room (designed by participating resident see below). Revised data collection tool b. How are underlying/root causes (see #13.b) addressed by the intervention(s)? (List each cause, whether it is addressed, and if so, how it is addressed.) Lack of/ erroneous problem list --- feedback concerning performance, educated on rational and need Lack of clear working definition --- provided list of anatomic CKD conditions Lack of uniform egfr calculation --- adopted 0.413 as calculation constant 15. Who is involved in carrying out the intervention(s) and what are their roles? Faculty and fellows (and nurse practitioner). The resident is serving as a higher level (data analysis) role. 16. The intervention will be/was initiated when? (For multiple interventions, initiation date for each.) The interventions were started in mid June after above meeting. D. Check 17. Post-intervention performance measurement. Is this data collection to follow the same procedures as the initial collection of data described in #11: population, measure(s), and data source(s)? Yes x No If no, describe how this data collection Data collection tool was clarified and modified 18. Performance following the intervention. a. The collection of the sample of performance data following the intervention: Data for the intervention period July through September 2013 patients were collected and analyzed in October 2013.
b. If the data collection has occurred, what is post-intervention performance level? (E.g., for each measure: number of observations or denominator, numerator, percent. Can display in a data table, bar graph, run chart, or other method. Can show here or refer to attachment with data.) Time Period Baseline: 2/1 4/15/13 Post-Intervention; 7/1 9/30/13 # Patients Meeting Inclusion Criteria If Included, # with CKD Identified by Criteria If CKD Identified by Criteria, # with CKD in Problem List 158 70 44% (70/158) 18 25% (18/70) 162 87 52% (87/162) 70 80% (70/87) E. Adjust Replan 19. Review of post-intervention data and identifying continuing/new underlying causes. a. Who will be/was involved in reviewing the post-intervention data, identifying underlying (root) causes of the continuing/new problem(s), and considering possible adjustments to interventions ( countermeasures ) to address the causes? Briefly describe who is involved, how (e.g., in a meeting of clinic staff), and when. In December the participants (faculty and fellows along with resident) met during our usual Friday division meeting time to analyze and collate results. Data for each provider, and stage of CKD were analyzed to identify variances and were compared to group averages. Overall the missed rate (# of missed CKD/total patients) per provider was reduced from 26% to 10%. This information was provided to participants. This gives the provider an idea of the percentage of charts with missing CKD where creatinine was check (or qualifying diagnosis). Baseline and Post First intervention Results (# of missed CKD/total patients) Each row represents one provider Baseline After intervention total misses % total misses % charts error charts error 3 0 0% 21 6 29% 2 1 50% 2 1 50% 8 2 25% 18 0 0% 8 3 38% 5 1 20% 18 4 22% 24 1 4% 24 4 17% 34 1 3% 36 6 17% 30 3 10% 24 7 29% 21 3 14% 27 12 44% 7 1 14% 150 39 26% 162 17 10% b. What are the primary underlying/root causes for the continuing/new problem(s) that the project can address? (Causes may be aspects of people, processes, information infrastructure,
equipment, environment, etc. List each primary cause separately. How the intervention(s) address each primary underlying cause will be explained in #20.c.) The main problems identified in the data are: Some patients with slowly progressive CKD that continue to be missed (usually diagnosis like RTA etc that are CKDI, but are at risk for acute kidney injury if there CKD is not recognized during an acute illness) Some problems continue with staging CKD versus recovering acute kidney injury. Causes that underlie these problems are: Forgetting to get CKD on problem list after labs back Thecurrent data collection tool is inadequate for accurate recording of the correct CKD in problem list, and will need to be re revised. Not aware of or not following routine procedures to assure listing diagnosis F. Redo 20. Second intervention. a. The second intervention will be/was initiated when? (For multiple interventions, initiation date for each.) January 1 2014 b. If the second intervention has occurred, what interventions were implemented? Education Emphasis on getting CKD on problem list after labs back Improved tool Revised data collection tool Improved standard procedures: Include looking back for CKD criteria on prior visit Using order entry to add ckd dx at time of clinic urine ordering If unsure will code AKI on problem list (rather than CKD) Checking problem list at time of attestation for patient seen by fellow / resident c. How are continuing/new underlying/root causes (see #19.b) addressed by the intervention(s)? (List each cause, whether it is addressed, and if so, how it is addressed.) The interventions are designed to hopefully focus on the CKD being put in problem list in the nonclinic setting (pre clinic or post) since the clinic environment is not optimal for chart review and the Michart system is often too slow to use in clinic. For follow up AKI patient either CKD or AKI will be coded and acceptable. Data collection tool revised to improve ability to compare problem list ckd staging with acutual ckd staging. G. Recheck 21. Post-second intervention performance measurement. Is this data collection to follow the same procedures as the initial collection of data described in #11: population, measure(s), and data source(s)? Yes x No If no, describe how this data collection Data collection tool revised to improve ability to compare problem list ckd staging with acutual ckd staging.
22. Performance following the second intervention. a. The collection of the sample of performance data following the intervention(s) either: Will occur for the period: Has occurred for the period: 1/1/14 3/31/14 b. If the data collection has occurred, what is the performance level? (E.g., for each measure: number of observations or denominator, numerator, percent. Can display in a data table, bar graph, run chart, or other method. Can show here or refer to attachment with data.) Time Period Baseline: 2/1 4/15/13 Post-Intervention; 7/1 9/30/13 Post-Adjustment 1/1/14 3/31/14 # Patients Meeting Inclusion Criteria If Included, # with CKD Identified by Criteria If CKD Identified by Criteria, # with CKD in Problem List 158 70 44% (70/158) 18 25% (18/70) 162 87 52% (87/162) 70 80% (70/87) 184 134 73% (134/184) 117 87% 117/134 Deidentified provider level data (boxes through cycles do not align to provider ie the same provider did not get a 0% all 3 cycles) Percent CKD missed on PSL Cycle 1 Cycle 2 Cycle 3 Best 0% 0% 0% 17% 3% 6 17% 4% 9 22% 10% 10 25% 14% 10 29% 14% 14 38% 20% 17 44% 29% 18 Worst 50% 50% 29 Total 26% 10% 8% H. Readjust 23. Review of post-second intervention data and identifying continuing/new underlying causes. a. Who will be/was involved in reviewing the data, identifying underlying (root) causes of the continuing/new problem(s), and considering additional possible adjustments to interventions ( countermeasures ) to address the causes? Briefly describe who is involved, how (e.g., in a meeting of clinic staff), and when.
The resident / fellow as part of their QI project (separately) reviewed / prepared data and the raw data and analysis was distributed to participating faculty. Further analysis (provider level error rate) were distributed later to faculty individually (deidentified data discussed in 6/6/2014 meeting). b. What are the primary underlying/root causes for the continuing/new problem(s) that the project can address? (Causes may be aspects of people, processes, information infrastructure, equipment, environment, etc. List each primary cause separately.) Summary of findings. On analysis of misses very few 3/17 were stage II CKD (none greater) and about half the others were debatable or very mild stage I CKD. Underlying causes. Some faculty that primarily dictate may not interact with problem list. If a dictating resident sees patient the, the attending may miss problem list review. In addition, when Michart is slow the information may not be added to the list. If no additional cycles of adjustment are to be documented for the project for Part IV credit, go to item #24. If a few additional cycles of adjustments, data collection, and review are to be documented as part of the project to be documented, document items #20 #23 for each subsequent cycle. Copy the set of items #20 #23 and paste them following the last item #23 and provide the information. When the project to be documented for Part IV credit has no additional adjustment cycles, go to item #24. If several more cycles are included in the project for Part IV credit, contact the UM Part IV MOC Program to determine how the project can be documented most practically. I. Future Plans 24. How many subsequent PDCA cycles are to occur, but will not be documented as part of the project for which Part IV credit is designated? We plan to move to next MOCIV project in June.(none). 25. How will the project standardize processes to maintain improvements? Ongoing education (especially of rotating residents but also new fellows, attending) of the standard expectation of egfr calculation and CKD inclusion in problem list. This will need to be done at the beginning of elective (or hire). The working definition of CKD will continue to be refined, ie which diagnosis/conditions should be considered CKD1 even if the egfr is normal. Optimally we would be able to generate automated egfr calculations in MiCHART. 26. Do other parts of UMHS face a similar problem? If so, how will the project be conducted so that improvement processes can be communicated to others for spread across applicable areas? Yes this is a small element for pediatrics but is a large issue in the Main and CVC hospitals (especially for comorbidity identification). J. Physician Involvement Note: To receive Part IV MOC a physician must both: a. Be actively involved in the QI effort, including at a minimum: Work with care team members to plan and implement interventions Interpret performance data to assess the impact of the interventions Make appropriate course corrections in the improvement project b. Be active in the project for the minimum duration required by the project
27. Physician s role. What are the minimum requirements for physicians to be actively involved in this QI effort? a. Interpreting baseline data and planning intervention: Will screen patients charts for the assign time frame, calculate egfr and assign CKD stage, and review record for diagnosis and CKD stage. Will participate in faculty discussions of the data analysis, identification of obstacles to CKD identification, assist in developing strategies for improved CKD identification b. Implementing intervention: In clinic will implement recommended actions to improve egfr calculation and CKD identification and problem list placement. c. Interpreting post-intervention data and planning changes: Will screen patients charts for the assign time frame, calculate egfr and assign CKD stage, and review record for diagnosis and CKD stage. Will participate in faculty discussions of the data analysis, identification of obstacles to CKD identification, assist in developing strategies for improved CKD identification d. Implementing further intervention/adjustments: Improvements in processes in clinic, signage in clinic, discussion of categorization. e. Interpreting post-adjustment data and planning changes: Will screen patients charts for the assign time frame, calculate egfr and assign CKD stage, and review record for diagnosis and CKD stage. Will participate in faculty discussions of the data analysis, identification of obstacles to CKD identification, assist in developing strategies for improved CKD identification 28. How are reflections of individual physicians about the project utilized to improve the overall project? Since CKD stage I is somewhat a judgment call (and a marker for patient to be followed longer term by at least PCP), this was where much discussion and reflection occurred (and many errors). In addition the difficulties in grading CKD became apparent for those with changing creatinines and egfr < 95 this complicated our attempt in improving CKD grading (not included in above data) BUT has enhanced our understanding of the importance of data collection tool design and education of faculty before data collection begins. 29. How does the project ensure meaningful participation by physicians who subsequently request credit for Part IV MOC participation? In addition to requiring the data collection and participation in analysis and development of interventions, we collected data on the individual participants adherence/improvement. 30. What are the specialties and subspecialties of the physician anticipated to participate in the project and the approximate number of physicians in each specialty/subspecialty? Pediatric Nephrology attendings # 8 Pediatric Fellow # 1 and Resident #1 (as QI not MOC) K. Project Organizational Role and Structure 31. UMHS QI/Part IV MOC oversight this project occurs within: x University of Michigan Health System Overseen by what UMHS Unit/Group? Pediatric Nephrology (Chief David Kershaw)
Is the activity part of a larger UMHS institutional or departmental initiative? No X Yes the initiative is:inpatient Michart coding initiative (and the overall goal to accurately code comorbities.) Veterans Administration Ann Arbor Healthcare System Overseen by what AAVA Unit/Group? Is the activity part of a larger AAVA institutional or departmental initiative? No Yes the initiative is: An organization affiliated with UMHS to improve clinical care The organization is: The type of affiliation with UMHS is: Accountable Care Organization type (specify which): BCBSM funded, UMHS lead Collaborative Quality Initiative (specify which): Other (specify): Who is the individual at UMHS responsible for oversight of the QI project regarding Part IV requirements? Name: David Kershaw Title: Division Chief Institutional/organizational unit/affiliation: Pediatric Nephrology Phone number: 734-936-4210 Email address: dkershaw@umich.edu 32. What is the organizational structure of the project? [Include who is involved, their general roles, and reporting/oversight relationships.] Lead and participant David Kershaw Faculty Participants Pat Gipson Debbie Gipson Neal Blatt Dave Selewski Matt Sampson Fellow Participant (as QI project) DongMei Huang Resident Participant (as QI project) Brendan Crawford 33. To what oversight person or group will project-level reports be submitted for review? Dr Valerie Castle, Chair of Pediatrics.