Tracking Multidisciplinary Outcomes in the Dialysis Patient Population

Abstract

With the increasing burden of meeting regulatory requirements amidst a downsized and managed-care environment, health care professionals are searching for costeffective methods that will meet current standards of excellence. Nowhere is this concept more evident than within the end-stage renal disease (ESRD) arena. In October 1994, a multidisciplinary committee consisting of nursing, physician, dietary, social work, and administrative representatives began exploring the cumbersome processes involved in demonstrating and communicating the delivery of quality patient care within our outpatient dialysis facility. Because several referring physicians have admitting privileges for dialysis therapies (including in-center hemodialysis, home hemodialysis, and home-automated and continuous ambulatory peritoneal dialysis), consistency in standards of delivery of care was an ongoing challenge. Furthermore, existing tools used to document and evaluate the delivery of care (ie, tracking processes and outcomes) were outdated. Before the actual work could begin, the barriers inherent to establishing regular meetings had to be overcome. The precepts integral to continuous quality improvement (CQI) were just beginning to infiltrate the organization. Despite some initial skepticism (inherent to any strategic change), members were eager to explore its application within the facility. Medical representatives were especially enthused by the idea of replacing old quality assurance activities with data-driven opportunities for improvement. Monthly meetings were scheduled, minimal attendance requirements were established and enforced, and meeting times were limited to one and a half hours. Frequent written and telephone reminders preceded the meetings. Attendance and participation were made a priority and were supported by administration. The committee quickly identified several opportunities for improvement including: (1) identification and improvement of patient outcomes related to important aspects of care for dialysis patients; (2) streamlining and improving multidisciplinary documentation processes and communications; (3) developing and implementing outcome data collection tools for CQI activities; (4) improving consistency between multidisciplinary standards of care and practice; (5) replacing old care planning systems (regulation-driven) with more meaningful and user-friendly tools that target actual problems and track progress toward their resolution; and (6) developing and implementing staff competency-based assessments. In January 1995, we began using the hemodialysis and peritoneal dialysis Outcome Tracking Tools (Figure 1) at Piedmont Dialysis Center (PDC) (Winston-Salem, NC). Subsequent introduction into five satellite units was finalized in June 1995. Figure 1 illustrates page 1 of the Peritoneal Dialysis Tracking Tool. The tool is a seven to eight page document that can be used to track important aspects of multidisciplinary care and patient progression toward goals. The important aspects of care include adequacy of the dialysis prescription, patient compliance, anemia, nutritional management, renal osteodystrophy, dialysis access, blood pressure control, diabetes control, performance of activities of daily living, comorbidities, adjustment to ESRD and the treatment regimen, family and social support systems, environmental! concrete needs, rehabilitation status, and specific unstable criteria. The peritoneal dialysis tool also tracks peritonitis and catheter-related complications. All team members document, at least monthly, on the tracking tool. Because no one discipline has ownership of care, all disciplines must review all aspects of care to assess how their individual interventions are affect-