Journal 6- QA/CQI Part 2

Tuesday, 27th 2009

QA/CQI meeting started off today at 10am with a pretty descent size attendance. At the meeting was the medical director, my preceptor and I, the clinical coordinator, QA/CQI coordinator, anemia manager, biomedical technician, vascular access coordinator, dietician, social worker, safety/ hazardous communication director, reuse technician, infection control coordinator, training/in-service coordinator, facility maintenance manager, peritoneal and home-hemodialysis coordinator. At the start of the meeting I was introduced to all team members by my preceptor. She clearly stated the role I would be playing in the review process. I was quite surprise at their warmth and receptive welcome address. However, I must admit I was a bit anxious of what was expected of me. Nevertheless, with all the information I had reviewed, I felt somewhat prepared.

The QA/CQI coordinator was the primary moderator for the meeting. She started off by reviewing the specific accountability tool on the QA report. Each member of the QA/CQI team has an individual tool that is specific to their area of accountability. For example, nutrition and bone management (phosphorus, calcium, PTH levels etc) are primarily managed by the dietician. During the meeting, as we reviewed the overall and individual patient data on bone management from the previous month, I observed a consistent trends of data falling out of range as specified by the clinical guidelines(60% of the patient were having problems with elevated phosphorus). In this process, the dietician explained why goals were not met and the same time she drafted out a plan on how to improve outcomes. One of her suggestions was for these patients to switch to a different phosphate binder (from RenaGel to Renvela). According to the dietician, evidence based reports clearly shows that Renvela is very effective in maintaining phosphorus and calcium level within therapeutic range , however the issue of cost( Renvela is one of the most expensive orally- prepared phosphate binders in the market) is something that might deter most patient from compliance. Therefore to improve compliance, the social worker suggested that these patients could apply for prescription assistance to the End Stage Renal Disease Network (ESRD).

As the meeting progressed, we reviewed other areas like patient mortality, safety programs review, blood pressure and anemia management, infection control, patient satisfaction and adherences to treatment. Etc. At that point, working closely with the infection control and vascular access coordinator, I was required to discuss some of the current issues with infection control. From the previous QA/CQI reports and the data’s from the current month, I observed that although infection reporting incidents were on the decrease, actual goals were still not met. One of the primary reasons for this was the problem of vascular access (Arterial-Venous shunts) and central venous catheter infections. Based on reviewed literature and the facility policy, I observed that the facility’s current clinical guidelines on accessing the different types of vascular access were not only supposedly efficient but also evidence based. Considering that, I was concern if the teammates were properly implementing these clinical guidelines in their practice. My suggestions was for the clinical educator to review to all direct care providers(nurses and patient care technicians) ,the facility’s policy and procedure on how to properly handle the different types of vascular access and the outcomes would be reevaluated in the next QA meeting.

On the issue of patient satisfaction and adherence, I observed that one of the primary reasons for lack of adherence and missed treatment was due to the time of treatment hours. The clinic operation hours are from 5am to 6pm, as a result majority of the working patient expressed dissatisfaction with this hours. My suggestion was for the facility to consider extending clinic hours (maybe to 9pm) to try to accommodate working patient and others that fall in this categories and the outcome would be evaluated in the next meeting.

At the end of this review, this was a wonderful learning experience for me. I learnt that the proper implementation of a QA/CQI program is a way that I can advocate for patients’ by collaborating with other members of the interdisciplinary team to ensure care provided is safe and effective and results in patient satisfaction. My preceptor was very impressed with the way I professionally addressed these issues to help promote positive patient outcomes. She thanked me for my resourceful contributions.

Clinical hours- 6