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OUTCOMES OF A PROGRAMME OF QUALITY IMPROVEMENT TO IMPROVE ATTAINMENT OF CLINICAL INDICATORS IN A CHRONIC DIALYSIS POPULATION
[Thesis]. Manchester, UK: The University of Manchester; 2017.
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Abstract
The management of people on dialysis is complex and requires a multi-disciplinary multi-professional approach. Observational studies in dialysis care have demonstrated a correlation between key clinical indicators and survival. However, achieving change in such a complex setting is difficult, with limited evidence from controlled studies of the effectiveness of interventions to improve these indicators. There is little evaluation of how best to implement and sustain known best practice into clinical care. UK renal registry data shows that whilst overall standards have improved, variation between units remains unchanged. This variation demonstrates that feedback alone is not enough to implement best practise, and that it is also necessary to understand cultural, structural, organisational and process factors.Quality Improvement (QI) is the process by which change can be implemented in systems. Methodologies vary, and highlight the need for bespoke approaches tailored to fit the clinical context. In 2010 the Salford Royal renal network introduced a two-year programme of QI to improve clinical indicators in dialysis care. Results were followed up on completion of the programme to establish whether outcomes were sustained. This thesis starts with a literature review summarising the evidence to date on modifiable factors affecting outcomes in renal replacement therapy and the rationale for addressing these factors in our chronic dialysis population, the development of QI in healthcare, and the evidence for its use to improve outcomes in renal replacement therapy.The first aim of this thesis was to analyse the outcomes of the Salford quality improvement programme. This found that the programme was successful in improving attainment of clinical indicators, and there was evidence of a reduction in hospitalisation and its associated costs. The second aim was to analyse in more detail one aspect of the programme- reduction in peritonitis. Key themes that emerged from this were the role of audit and continuous measurement, the importance of local leadership, learning from best practice elsewhere, and a patient-centred approach to reducing avoidable harm. The last question centred on the sustainability of results. Review of two years’ follow up data on urea reduction ratio and bacteraemia identified that whilst not all changes to practice were sustained, both improved clinical outcomes were broadly sustained. However, additional themes emerged from the analyses, highlighting the need to embed ongoing continuous review into practice. Finally, I have described potential future work arising from this thesis.