How to Use Quality Improvement Tools in Clinical Practice: A Primer for Nephrologists

• tools
• primer
• primary health care
• quality assurance
• health care
• quality improvement

Quality improvement is a common lexicon among practicing nephrologists. However, most clinical nephrologists have not received formal training in quality improvement methodology. However, the effect of performance measurement and data reporting in medicine and clinical nephrology has increased exponentially. Indeed, there has been substantial evolution in the size and scope of dialysis programs with increasing complexity and an aging patient population. Despite technical advances in dialysis, the notion of delivering consistent high–quality care remains a challenge. Common programs, such as the American College of Surgeons’ National Surgical Quality Improvement Program and the Center for Medicare and Medicaid Services End-Stage Renal Disease Quality Incentive Program, provide data on performance; however, these performance data are often not translated into improvement by many individual clinical programs. We contend that measurement alone is insufficient for affecting actual clinical improvement. Rather, individual clinical programs and providers require quality improvement skills to translate performance data into effective and sustainable health care system changes for their local contexts. Successful quality improvement programs have improved outcomes in other chronic diseases, including hypertension and diabetes (1–3).

In 2008, Medicare’s Final Rule of Conditions for Coverage mandated that the medical director of the dialysis unit be accountable for the quality, safety, and care of the facility. Most recently, the Centers for Medicare and Medicaid introduced the End-Stage Renal Disease Quality Incentive Program, which results in payment reductions in subsequent years if specific yearly quality metrics do not meet required targets. The introduction of the balanced scorecard and other quality assessment tools (e.g., patient experience metrics) have proliferated within nephrology practice. Given that nephrologists are continually faced with external pressures (e.g., regulatory and financial) coupled with the notion of quality, it is important to educate ourselves that there is, indeed, an ethical mandate for quality improvement within the continuum of nephrology education and professionalism (4,5).

We hypothesize that, in general, programs and providers are not sufficiently familiar with available quality improvement tools and how to incorporate them into practice, which is the focus of this Moving Points in Nephrology feature in the Clinical Journal of the American Society of Nephrology. We will aim to review the principles of quality improvement and the tools that are needed to translate performance measurement into the changes that actually matter for patients. To this aim, we had the privilege in assembling a team of leading nephrologists with specific expertise in quality improvement. Throughout this feature, we will use a longitudinal practical example to illustrate various quality improvement methods and tools that can be used at different stages in the quality improvement process, namely:

• (1) How to begin a quality improvement project,

• (2) How to diagnose a solution to a quality of care problem,

• (3) How to measure and interpret quality improvement data, and

• (4) How to sustain change and support continuous quality improvement.

It is important to recognize that we aim to illustrate the methods and framework of quality improvement for clinicians, and it is not our intent to dictate quality indicator measurement, how to identify local quality of care problems, or the local changes that are needed to improve care. In addition, these four articles do not provide a comprehensive list of all of the existing quality improvement tools, and we encourage nephrology health care professionals to advance their quality improvement expertise through practice and experiential learning.

There is no single right way to do quality improvement. Our primer’s ultimate goal is to illustrate the recipe for success in quality improvement, which will require both appropriate methodology and critical understanding of the context in which improvement activities occur.

• Copyright © 2016 by the American Society of Nephrology