KQuiP for Scotland

Kidney Quality Improvement Partnership (KQuIP)

Improving care for patients with kidney disease in

Scotland?

Scottish Renal Association27th - 28th October 2016

Graham Lipkin, Co-chair of KQuIP, Clinical VP Renal Association

Ron Cullen, CEO UKRR

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Key Message for KQuIP: Berwick Report

Place the quality and safety of patient care above all other aims for the NHS. (This…is your safest and best route to lower cost.)

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• Introduction

• Quality assurance vs Quality improvement

• Barriers to improving quality of care?

• What is KQuIP?

• National priorities-developing projects

• What can KQUIP offer to help you?

• Scotland & KQuIP-next steps

Overview


Background

UK kidney community has a proud history of innovation, high quality measurement and working together with our

patients


http://www.bing.com/images/search?q=renal+association+images&id=5F56A7C67D221518DFBDE0C4A4E7BF7EF16D4D70&FORM=IQFRBA


• Comprehensive• Renal Biopsy• Access• ….

• Serial outcome comparisons


Patient involvement-Scotland


Community coming together


Clinical Practice Guidance: Guidance for UK Practice




UK Renal Registry 18th Annual Report 2015

Access at initiation of dialysis


Variation: Pre-emptive transplantation


Guidance on quality improvement


Deck chairs on Titanic


Notable quality improvements

• Dialysis catheter-associated MRSA bacteraemia

• Improved AV Fistula access rates

…..successful ongoing QI projects

The knowing - doing gap – sustainability• Embed in everyday unit practice

• Education-tools for team to build



Children and adults

England and Home Countries

Why is KQuIP different?

From within renal community

Constant

Embed quality improvement as part of the day job!


Design Event: Coming together to mould KQuIP


Barriers to improvement in renal community

• Perceived lack of time*

• Limited sharing of good practice

• Lack of support for developing QI projects

• Limited training in leadership and QI methodology

• Culture of our health system which provides too little focus on improving quality.

• All change


What is needed to enable quality Improvement

• Supportive structure for clinicians in combination with patients focused around existing regional delivery structures

• Developing ‘basket’ of QI projects

• Peer support between units and networks-sharing

• Effective educational and leadership resources

• Culture change and ongoing commitment

• Research in improving quality



KQuIP is a dynamic network of kidney health professionals, patients carers and Industry …committed to developing, supporting and sharing quality improvement in kidney services…. in order to enhance outcomes and quality of life for patients with kidney disease.


KQuIP ambitions? - It will support NOT replace


KQuIP development

Programme Board

Workstream Co-chairs Group

6 Workstreams

KOG

FACULTY


KQuIP Workstreams

DevelopmentDal Hothi and Richard Fluck

Measurement Katie Fielding

Supporting NetworksJohn Stoves

CommunicationPaul Bristow

ProjectsHugh Gallagher

RA/BRS Patient SafetyKaty Jones


What is needed to enable quality Improvement

• Supportive structure for clinicians in combination with patients focused around existing regional delivery structures

• Developing ‘basket’ of QI projects

• Peer support between units and networks-sharing

• Effective educational and leadership resources

• Culture change and ongoing commitment

• Research in improving quality


What can KQuIP add?

Cohesive inclusive QI support

Project management support

Support Renal Networks: advice and education

Repository of projects, QI resources, methodology and education

QI education and leadership support (webinar-video, Courses)

Professional society support to Renal Units

Registry: metrics/expertise/analysis

KQuIP: dedicated QI sessions at the UK Renal Week

Sustainability and stability


KQuIP – How will it support renal quality improvement?

National

• Strategic level through advice to NHSE CRG, Home Countries NHS

• Central UK Renal Registry project management and faculty

• Online repository

Regional supporting existing Renal Clinical Networks

• UK Renal Registry/KQuIP quality improvement day

• Regional project management support

• Peer assist model


KQuIP - Driving renal quality improvement

Local unit, you and me

• Education and support materials - the go to place

• Peer assist (Share - ‘ask a friend’)

• Support for local projects

• Clinical QI leads (Projects QI leads - Medical and MDT)


Community priorities for quality improvement

• Improved access to home dialysis therapies

• Access to kidney transplantation

• Acute kidney injury (prevention, early diagnosis and management)

• Improving AV fistula access rates

• Paediatric to adult transition

• Optimising patient engagement, shared and self care

• Improving patient safety


KQuIP priorities: Moving to delivery

1. Enable development of 3 national projects (Workstreams)

2. Roll out regional KQuIP/UK Renal Registry days (UKRR/Faculty)

3. Web development/knowledge management platform (UKRR)

4. Extend faculty (Health Foundation Q Initaitive)

5. Embed education and training QI and leadership (LTMD and MDT)

6. Secure further funding and link with NHS QI arms (Workstreams)

7. Build link to safety


Training in leadership & QI methods


• Involve network of Renal Registrars in QI projects

• Embed QI methodology training

• Pay equal or greater focus to

training MP Team

Teaching the QI Leaders of the Future


Development of renal QI projects

+Transplant First:

Addressing inequality of access to renal transplantation across

the West Midlands

Kerry Tomlinson

Background: Identifying the problem

ESRDTransplant

listTransplant

•UK RR 2014 report median time to listing•488, 598, 641, (683), 712, 765, 787, 867


Pre-emptive transplant rates are lower than average


Project Background

Project mandate; Wmids Renal Expert Advisory Group

(Clinically driven)

Aims:

1. Reduction in the excessive waiting times to renal transplantation in the West Midlands

2. Improve access to renal transplantation for all patients in the west midlands

Full mandate and documents on website www.wmscnsenate.nhs.uk


http://www.wmscnsenate.nhs.uk/

+Project Structure

KQUIP

UKRRR

ODT

NICE

Taking organ

transplantation to 2020 LDKT

2020

•Identify data required, its source and obtain agreement to share data across the region•Agree formatting and regularity of reporting, e.g. quarterly audit and feedback of total transplant, live donor, deceased donor and pre-emptive transplant listing rates at each unit

•Identify repository for data

•Develop infrastructure for audit, review and reporting, e.g. RCA and audit of all patients starting RRTwithout a transplant list status

Data, measures and implementation (Kerry Tomlinson )

•Identify clinical standards and guidelines needed to improve access to transplant e.g. written acceptancecriteria for acceptance on kidney transplant waiting list

•Identify where documents already available and identify gaps, developing regional standards and guidelines as required

Standards and guideline (Nick Inston )

•Map the current patient pathways by renal unit across the region

•Co-design exemplar pathways with patients and clinicians in line with agreed standards and guidelines

Pathways ( Kerry Tomlinson)

•Collate information used across the region and upload to SCN website•Identify any gaps and develop further resources as required

Patient information (Helen Spooner)

•Identify training needs of all project participants, e.g. QI for unit leads and patient representatives

•Source/design, cost and deliver training

•Establish action learning sets

•Design first transplant education and audit event to share best practice, for roll-out annually thereafter

Education (Cecily Hollingworth)

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Project and

mandate approved

Transplant units

Renal units

Patients and carers

SCN

External experts

Project launch event July 2015

Shared Data, Successes and Challenges


Pathways

2 all day pathway redesign events

Some QI training included

5 CPD points from RCP and RCN reflective learning tool included

Opportunity to hear patient voice

Units worked on own pathways

Work on hand off between units

Pathways very varied and need to be designed and delivered locally with support

•Target audience from each unit•CKD consultant and nurse•Transplant consultant and nurse•Directorate manger•Data Lead•Patient representative•Open to trainees


Brendan's Voice

"When my kidneys failed, getting a kidney transplant became the most important thing that I had ever wanted in my life. I have never wanted anything more and never will.

Each step of the way I was accompanied by a desperate longing for it to happen, and every setback and delay was something I felt acutely, and caused a lot of anxiety"


Data: What will we achieve? (What success looks like)

95% of all CKD 5 patients will have a documented transplant decision

West Midlands will achieve >95% patients starting RRT with a transplant status

> 50% of patients will be listed pre-emptively

The West Midlands will have the highest rate of pre-emptive listing in the UK

The wait for deceased donor kidneys in the West Midlands will be in line with the national average or better

We will be in the top 50% of transplant units for pre-emptive transplants


Enhanced dashboard - Registry support


Early data

• Commonest cause of missing transplant listing is late referral

• Some immediate policy differences spotted (e.g. when to do cardiac catheter)

• Units can spot patterns in causes e.g. from feeder hospitals/clinics

• Needs some more refining

• Now planning to look at new patient listings (should have done before!)


Standards and guidelines

Discussion re BMI cut off

Defined when to workup

Did not change referral threshold


Patient information

•Patient information collated

•Working with patients to review current information and identify gaps

•Aim to produce core information resources

•In conjunction with the RR, ‘Donor View’, an online programme to support live donors through the donation process, is in development

Donor Patient View


Education

Encouraged enrolment in Massive Open Online Course (MOOC): Improvement FUNdamentals

http://www.nhsiq.nhs.uk/capacity-capability/improvement-fundamentals.aspx

Absorbed and delivered in other workstreams

People much happier with doing rather than being taught

You need QI methodology but not everyone needs to know it


http://www.nhsiq.nhs.uk/capacity-capability/improvement-fundamentals.aspx

Challenges

Tension

Between facilitators/participants

Between units and opinions

Between project leaders and their own units

Between project teams and their other roles, People (Consultants), Resources

To complete project

To work in different way

• Designated staff roles

• More clinic time

Post its


How have units found it: negatives

Staffing shortages with nurses as well as Consultants to improve transplant issues, this includes link nurses time as well

Consultants not documenting

Whole process was slower or delayed due to Consultant shortage

Software barriers – still unable to report all CKD5 patients on renal IT system

Lack of time for individual units to discuss changes


How have units found it?: positives

Transplant status being recorded on all patients, which will make auditing easier

Increased communication

Working with other units to improve transplantation and work together for a better patient experience

6 project arms covering work-up all the way through process to listing

Highlighted pathway delays and led to re-design

We now have a Transplant Co-ordinator in post

Better collaborative working to improve patient experience

Improving transplant profile for staff and patients

Identified timescales and how different members of staff contributed to the pathway

Pathways changes already evident

Better data to influence decisions


How sponsor team have found it

Time needed can’t be overestimated

Project support is key

Have to rely on engagement of units and work hard to keep enthusiasm

Patient engagement is difficult

Data collection is very difficult


Improving access to home therapies: KQuIP support?

Home First

Project development• Projects WS• Comms• Metrics

Regional scaling• PM support• Network• KQuIP/UKRR day• Education, LTMD

Peer assist modeKQuIP faculty

ConferencesKQuIP sessions

Knowledge managementplatform


The Think Kidneys

Acute Kidney Injury programme

Think Kidneys AKI Programme


Think Kidneys AKI Programme

Who is at risk?

When do people sustain AKI?

How should patients with AKI be

managed?

What do people need to know?


Improving diagnosis: using changes in serum creatinine

Laboratory definition and standardisation


NHS professionals, AHPs, commissioners, care homes etc

• Algorithm into pathology lab systems

• Acute care bundles

• Primary Care guidelines

• Medicines optimisation

• Patient information

• Paediatric guidance

• Care home guidance and educational resources

• National CQUIN for commissioning

Outputs and resources-resource pool


www.thinkkidneys.nhs.uk - summary

Think Kidneys

Has delivered system levers

Providing a framework for action

Raised the profile

It is supportive of other change agents


http://www.thinkkidneys.nhs.uk/

Wealth of resources to Share and replicate

Units have learnt QI Methodology


Transforming Participation in CKD programme

• Can PAM/CS-PAM/PROM/PREM measures be collected routinely within renal units?

• Is the PAM related to PROM/PREM/Clinical Measure results?

• Can we introduce interventions that will increase a patient’s and team’s activation?

Co-production as a core value


An activated person has the knowledge, skill and confidence to manage their own health and care

This means

• making informed choices

• being a partner in their own care

• self management and prevention

Activation varies within age, income, education

What is ‘activation’?


A developmental scale


What have we achieved? Phase 1 - embedding

•800 ‘Your Health’ surveys returned to UKRR

•400 CS-PAM surveys returned – landscape

•Data returns to clinical teams

•Additional PV screens developed to view results alongside clinical data

•Changes in practice

•Report on results will be available November 2016 and renal units are working on actions to take following their unit results


Peer Review

Quality Assurance & Quality Improvement

KQuIP:Scottish Approach?

SRRChair: Wendy

MetcalfeTech director: Jamie Traynor

SMASAC:Graham Stewart

CSO Advisor:Paddy Mark

TPDs: Scott Morris,

Dave Walbaum, Graham Stewart,

Paddy Gibson

CDs:Drew Henderson,

Carol Brunton, Muniraju Thalakunte,

Arthur Doyle, Jane Goddard, Rob Peel, Ray

Wan, Malcolm Hand, Scott Morris, Colin

Geddes

QI:Pete Thomson, Stewart

Lambie (SPSP)Mark MacGregor, Ken

Donaldson (GenQ), Simon Watson (NHSI)

ISD

NHS Boards

NES RCPs CMO CSO

SRAConvenor:

Scott Morris

NHS Health

HIS

NHS24SAS

NSS

UKRAScotland rep:

Mark MacGregorSKF Chair:

Keith Hodkinson

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Embedding QI in kidney care in Scotland

Strengths

Strong informal network

Motivated individuals-history of delivery

Cohesive, collaborative

SRR

SRA

Patient View

Weaknesses

No central renal policy/direction**

Variation between units**

No formal Scottish Kidney Network

Limited Project management


How could KQuIP further support embedding QI into Scottish renal services?

•Leadership development & education•Share resources-online repository/Knowledge management

•Project development (national & local)•Metrics - Registry•Central project management support/communication

•Peer assist model•Active patient safety group


1. Interest in collaborative/network?

2. SKi-Net: what structure is required?

3. Adopt KQuIP priorities or establish own?

4. How do we interact with SG/Boards/KQuIP?

5. How do we develop and use QI faculty?

6. What more data do we need, and how do we collect?

7. Resource?

Next steps?


KQuIP welcomes youEnabling you and your team to improve quality

and safety

www.thinkkidneys.nhs.uk/kquip/

KQuiP for Scotland

Health & Medicine

Transcript of KQuiP for Scotland