Ensuring Patient Safety and Quality Measures for RRT in AKI 2 Eileen Lischer MA, BSN, RN, CNN University of California, San Diego
Today we may be doing what we can, but tomorrow we can improve Hughes, RG. Patient safety and quality: An evidence-based handbook for nurses. AHRQ Publication; March 2008
History of Health Care Outcomes Accurate hospital statistics are much more rare than is generally imagined, and at best they only give the mortality which has taken place in the hospitals... Florence Nightingale, 1863
ANA Foundational Documents The Code of Ethics for Nurses: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient Nursing: Scope & Standards of Practice, Standard 7: The registered nurse systematically enhances the quality and effectiveness of nursing practice
CQI process Decide on the data collection points- What do you want to monitor? Mandated- water quality Programmatic- Clearances Adherence to order set Arise out of QVR data
PDSA Cycle
PDSA Model for Improvement IHI reprinted with permission Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; It should also define the specific population of patients that will be affected. Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to an improvement. Selecting Changes All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement. Testing Changes The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning
PLAN Objectives of this cycle- AIM statement Who, What, Where, When, How of the interventions Baseline Data QVRs, literature review Establish measurements to study effectiveness of change
Features of Good Aim Statements Specific Measurable Aggressive yet Achievable Relevant Time-bound
DO Structure and Process Availability of resources Plans, roles of participants Actions taken
Study Results Compare to benchmarks and predictions Summarize what was learned All improvement requires making changes, but not all changes result in improvement.
ACT List changes Act to hold or revise interventions Embed actions into practice Re-evaluate impact of changes.
CRRT Prescription Compliance QVR data Antidotal reports System surveillance and identification of errors.
PLAN Improve adherence to therapy prescription Look at baseline data collected and review QVR data-current threshold Self reporting of errors, less than 5% Establish a system to review therapy and collect data.
Plan All systems are checked twice a day by charge nurse. In am and again in afternoon Data tool designed to collect data All RNs check actual therapy against MD written order set. Compliance targets were established Deviances are recorded and investigated Information is tracked and reported at monthly PI meeting or multidisciplinary CRRT committee
Encounter
Indicators and Thresholds Daily weights initial target 75% Intake and output compliance- +/- 100 mls for a 24 hour period. Initial target 75%
DO Dialysis charge nurse checks all CRRT systems twice a day at minimum. All systems are checked against what is actually running and order set. Data collection tool is used to record exceptions to ordered therapy
Study Look at data and compare to threshold Indicator tracking log- to trend changes in compliance Monthly PI meeting to study and review quality data.
Indicator tracking log Acute Dialysis CQI Quality Indicator Tracking Log for FY 2009-2010 INDICATORS Threshold 2008-2009 July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun IHD Treatment Record Audits: 90.0% 97.6% Patient Safety Goals - 100% 100.0% 99.8% Machine Safety Check - 100% 100.0% 99.4% Other Record Element -90% 90.0% 93.6% IHD Pre Weight Audit 90.0% 92.0% IHD Post Weight Audit 90.0% 90.1% Staff Credentials 100.0% 100.0% IHD/RO Machine Cultures 100.0% 95.3% IHD/RO Machine Cultures Jail 100.0% 98.3% CRRT: Hemodialysis RN 95.0% 97.8% CRRT: ICU RN 85.0% 86.0% CRRT: Weights 90.0% 94.7% Quarterly Preventative Machine Maintenance 100.0% 100.0% Annually Water Analysis 100.0% 100.0% Staff Competency Testing 100.0% 100.0% Policy and Procedure Audit Only URR=>65% Audit 68.8% IHD Fluid compliance Audit 82.5% 1
Problem tracking log To identify the indicators that are below threshold. Brings them into focus Design action plan to correct Track until meet compliance for three months.
Problem tracking log ACUTE DIALYSIS PROBLEM TRACKING LOG FOR JULY 2009-JUNE 2010 For problems tracked > 1 year, see minutes of the previous July. Acute Dialysis Indicator July August Sept Oct Nov Dec Jan Feb Mar Apr May June Threshold (% Met) Date of Initial Entry Result (% Met) at Initial Entry Overall Plan Review Frequency Responsibility Date Threshold Met Monthly RESOLVED Threshold (% Met) Date of Initial Entry Result (% Met) at Initial Entry Overall Plan Review Frequency Responsibility
ACT List actions that were effective in meeting threshold Involving a multidisciplinary team-encouraged ownership Reporting results of data collection to each ICU Enlisting the help of the CNS in the unit when problems identified Using frontline nurses to teach annual skills days Establishing an environment of safety not blame Embed these changes in the day to day practice
Currently Daily weights started at 75% compliance and now are at 93% Intake and output compliance started at 75% and now 83%. Some units are consistently at 100%.
Conclusion Organized PI process needs to be developed Indicators and thresholds established with help of a multidisciplinary team Data tool and data collection initiated Study data, identify areas of improvement Enlist your champions to design the plan Re-evaluate.
Never doubt that a small committed group of people can change the world, in fact it s the only thing that ever has. ---- Margaret Meade