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  • 1.JHQ Web Exclusives November/December 2007W6-1 CONTENTS WEB ARTICLES W6-18 q&a: Tracy Sklar on AdvancingImprovement in Acute CareWayne E. Soo Hoo W6-3 Non-Nephrologist andNephrologist PerspectivesTracy Sklar, MSc MBA, is the vice president forquality and service excellence in the care man-on Implementing a Chronic agement department of Catholic Healthcare WestKidney Disease Guideline(CHW). She has worked in the care managementdepartment for 6 years and at CHW for more thanMeenal B. Patwardhan, David B.18 years. Sklar is a highly effective process facilita-Matchar, William E. Haley, Gregory P. tor with strong analytical skills, and she has a well-Samsa documented record of leading successful clinicalProviding care consistent with clinical practiceimprovement projects that have resulted in bothguidelines for individuals with advanced chronicimproved patient outcomes and cost savings.kidney disease (ACKD) is known to improveoutcomes. Nephrologist and non-nephrologistperspectives regarding ACKD and preferences fortools to optimize patient management were iden-tified through focus group interviews. Six focusgroups for nephrologists and non-nephrologistsDEPARTMENTSfrom geographically distinct areas were conducted.Physicians discussed methods of identifying pa-tients, the referral process, overall management ofW6-21 Media ReviewsACKD, the use of practice guidelines, and percep-tions regarding guideline implementation tools.Focus group insights were used to develop toolsW6-24 Quality NETworkfor implementing a guideline to optimize ACKDpatient management.W6-26 Quality Products andResourcesVol. 29, No.6www.nahq.org/journal/online/ 2007 National Association forHealthcare Quality

2. JHQ Web Exclusives November/December 2007W6-2Web Exclusives MissionVision Journal for Healthcare Quality is a professional forum Journal for Healthcare Quality is the first choice for that continuously advances healthcare quality prac-creative and scientific solutions in the pursuit of tice in diverse and changing environments. healthcare quality.Editor in Chief Editorial BoardReview Panel for This Issue Luc R. Pelletier, MSN APRN BC Lecia A. Albright, CPHQChristy L. Beaudin, PhD LCSW CPHQ CPHQ FNAHQ FAAN LARA Consulting, LLC FNAHQ Healthcare Consultant Spotsylvania, VA Los Angeles, CA San Diego, CA Christy L. Beaudin, PhD LCSW CPHQJean A. Grube, PhD MBA MSN FNAHQ Special Issue Editors Childrens Hospital of Los AngelesMadison, WI Jean A. Grube, PhD MBA MSNLos Angeles, CATracey Lynn King, MSN RN CPHQ Medical College of Wisconsin CCRN CPUR Madison, WI Sue Boisvert, MHSA RNCape Coral, FL Parkview Adventist Medical Center Diane M. Peters, MS RN NHABrunswick, ME Pathway Health Services White Bear Lake, MN Diane Brown, PhD RN CPHQ FNAHQ Kaiser Foundation Hospitals Research Editor Pittsburg, CA Robert J. Rosati, PhD Jacqueline Fowler Byers, PhD RN Visiting Nurse Service of New YorkCPHQ CNAA FAAN New York, NYUniversity of Central Florida Orlando, FL Interviews Editor Steven Douglas Chinn, DPM MS CHE Susan V. White, PhD RN CPHQ CPHRM CPHQ FNAHQ VA Palo Alto Healthcare Systems Healthcare Consultant Palo Alto, CA Windermere, FLThe Joint Commission Oakbrook Terrace, IL q&a Editor Joann Genovich-Richards, PhD MBA Deborah M. Flores, EdD MBA RN MSN RN Corpus Christi Medical Center Sharendipity Enterprises, Inc. Corpus Christi, TXSterling Heights, MI Quality NETwork EditorLenard L. Parisi, MA RN CPHQ FNAHQ Daniel H. van Leeuwen, MPH RN Metropolitan Jewish Health System CPHQBrooklyn, NY St. Peters HospitalKevin C. Park, MD CHCA Albany, NYAttest Health Care Advisors LLC Las Vegas, NV Media EditorPamela K. Scarrow, CPHQ Jean A. Grube, PhD MBA MSN American College of Obstetricians Medical College of Wisconsinand Gynecologists Madison, WI Washington, DC Senior Managing EditorWayne E. Soo Hoo, PhD MSN RN Barbara Hofmaier, MAT CPHQ Glenview, ILMercy San Juan Medical Center Carmichael, CA Graphic DesignerSandra E. Ward, MA MS RN CPUR Eric Trisilla CPHQ Glenview, ILHIP Health Plan of New York New York, NY Editorial Assistant Meaghan Olson Glenview, IL NAHQ 20062007 Board of DirectorsHeidi Benson, MS RN CPHQ FNAHQCarol Lee Hamilton, JD MPA RN CPHQPresident FNAHQThomas M. Smith, MA RN CPHQ Member Services DirectorPresident-Elect Linda Scribner, BA CPHQAnna Marie Butrie, MSN MPH CPHQ Professional Development DirectorFNAHQ Joan Boldrey, MEd MS RN CPHQImmediate Past PresidentEx-Officio, HQCB Chair (2007)Sandra Grinder, MSN RN CPHQ Stacy Sochacki, MSSecretary-Treasurer Ex-Officio, Executive Director Journal for Healthcare Quality is an official publication of the National Association Quality. The association reserves the right to accept, reject, or alter all editorial Vol. 29, No. 6 for Healthcare Quality (NAHQ) and is a refereed journal. Journal articles express and advertising material submitted for publication. Advertising published in thewww.nahq.org/journal/online/ the authors views only and are not necessarily the official policy of NAHQ or thejournal does not imply endorsement of products and services. Members of the 2007 National Association for editors of the journal. The Information for Authors is available at www.nahq.org/ National Association for Healthcare Quality receive a subscription to Journal for Healthcare Quality journal/resource/pubsauth.htm or from the editorial office of Journal for HealthcareHealthcare Quality as a benefit of membership. 3. JHQ Web Exclusives November/December 2007W6-3 Non-Nephrologist and Nephrologist Perspectives on Implementing a Chronic Kidney Disease Guideline Meenal B. Patwardhan, David B. Matchar, William E. Haley, Gregory P. SamsaChronic kidney disease (CKD) is a conditionAbstract: Providing care consistent with clinical practice that involves gradual loss of kidney functionguidelines for individuals with advanced chronic kidney dis- over time. The condition is divided into stagesease (ACKD) is known to improve outcomes. Nephrologist and of increasing severity, and the final stage is referred to as end-stage renal disease (ESRD), non-nephrologist perspectives regarding ACKD and preferenc- or advanced CKD (ACKD). ACKD, involvinges for tools to optimize patient management were identified minimal kidney function, is a source of sig- through focus group interviews. Six focus groups for nephrol- nificant mortality and morbidity in the United ogists and non-nephrologists from geographically distinct States (McCrory et al., 2002; Pereira, 2002; Schoolwerth et al., 2006). areas were conducted. Physicians discussed methods of iden- The prevalent population of individu-tifying patients, the referral process, overall management of als with ACKD is projected to increase fromACKD, the use of practice guidelines, and perceptions regard- 325,000 in 2003 to 660,000 by 2010 (National ing guideline implementation tools. Focus group insights Kidney Disease Education Program [NKDEP], 2006), and the annual mortality rate for ACKDwere used to develop tools for implementing a guideline to patients is approximately 20% (Schoolwerth etoptimize ACKD patient management. al., 2006). Providing optimal care in the stage prior to ACKD, is known to improve outcomeseven though a guideline for improving qualityKey Words by slowing progression of the disease and by of care during ACKD that addresses all clinically reducing mortality and morbidity if the indi- chronic kidney diseaserelevant management areas has been developed vidual progresses to ACKD (Obrador et al., (Renal Physicians Association, 2002).focus groups 1999; Pereira, 2002; Schoolwerth et al.).It is well documented that mere creation and guideline implementation In order to optimize care of ACKD, early dissemination of practice guidelines is not suf- identification of the condition is essential ficient for practice improvement (McClellan, (National Kidney Foundation [NKF], 2002), butKnight, Karp, & Brown, 1997). To facilitate there is evidence that fewer than 20% of patientsimprovements in patient outcomes based on at risk for CKD are screened for the condition adherence to guidelines, a set of tools and strat- (NKDEP, 2006). Identification and management egies is needed. of ACKD patients occur in a range of settings: One systematic approach to develop- solely in a non-nephrologist (e.g., primary care ing guideline implementation tools is facili- provider, cardiologist, endocrinologist) practice, tated process improvement (FPI) (Matchar, solely in a nephrologist practice, or comanagedPatwardhan, Samsa, & Haley, 2006). FPI is between nephrology and non-nephrology prac-based on continuous quality improvement tices (NKF). Regardless of the setting, though,principles and involves (1) understanding the management of individuals with CKD is knownprocess, (2) identifying process failures and to be suboptimal. Further, the problem of sub- root causes, (3) developing tools to attack root optimal management remains, despite the fact causes, and (4) establishing a tailoring strategy that initiating appropriate treatment makes a(so that physicians can select tools appropriate difference. Several studies have demonstratedfor their practice situation). the impact of intervention on levels of hemoglo- FPI is well suited for quality improvement bin, malnutrition, permanent vascular access,in healthcare settings because it requires an and overall survival of individuals with CKDJournal for Healthcare Qualityexternal expert team (rather than busy clini-Web Exclusive (Brenner et al., 2001; Nissenson et al., 2001; cians) to develop guideline implementation Vol. 29, No. 6, pp. W6-3W6-17 www.nahq.org/journal/online/ Patwardhan, Samsa, Matchar, & Haley, 2007; tools. Following these principles, the research- 2007 National Association for Stack, 2003). Suboptimal management exists ers involved in the current exercise used FPIHealthcare Quality 4. JHQ Web Exclusives November/December 2007 W6-4to create a set of tools to overcome barriers to (an area of approximately