The national paediatric nephrology programme has evolved over the last 30 years to provide high class tertiary paediatric nephrology care to children with kidney problems in Ireland. Diagnosis with a kidney condition can be devastating and life altering for a child and their family. However, with support and careful specialised management, it is possible to maintain a good quality of life and plan ahead for renal replacement therapy as required. This planned approach must be delivered within an evolving health service and a changing society, while the focus should always centre on individualised care and a drive to improve the quality for the patient (Royal College of Paediatrics and Child Health 2011). This article is an overview of a quality improvement project. This initiative was undertaken as part of the criteria to complete a Diploma in Patient Safety the author undertook with the Royal College of Physicians of Ireland (RCPI).
Attendances at the specialist nephrology clinics are steadily increasing as it provides a national tertiary referral centre for nephrology. It also provides the only national paediatric renal transplant service for the care and follow-up for this cohort of patients is demanding and patient specific. The environment of clinic is not suited for the numbers attending and does not lend itself to good patient flow. With no dedicated administration support, attendances, patient details and follow up appointments are never captured cohesively. The nurse specialist was responsible for overseeing clinic outcomes and ensuring the secretary or ward clerk booked the appointments while the registrars requested investigations. Families were regularly phoning the clinic to clarify issues regarding not receiving an appointment or perhaps receiving two different dates. Also, there were many queries from families who were awaiting scans or tests which had not yet been requested by the renal team. On retrospective review of the figures, in a two-week period 64% of patients had an appointment made, leaving 36% with no normal follow up plan. In order to improve the safety and quality of the renal outpatient service, there must be increased focus on the area of attendance at clinic and follow up appointments within the specialist area.
The aim of this quality improvement initiative was to ensure that 100% of patients attending the renal clinic received a follow up appointment within 1 week of their attendance, by April 2015. It is widely acknowledged that the earlier deteriorating renal function is diagnosed, receiving specialised and appropriate management can prevent or delay end stage renal failure (Department of Health 2004). This can only be delivered upon if the patients are in the system and receive timely and planned care. The Health Foundation (2014) believe that poor systems cause poor results for the taxpayer, staff and patients and was not always caused by a lack of funding. In instances where a patient may not receive a correct appointment to return to the clinic, or perhaps become lost to follow up, the consequences are so enormous it is impossible to quantify for that family, for medical staff or the organisation. Therefore, objectives of this project include streamlining how we manage our clinics and capture attendances, by implementing a new process for appointments and improving team communication, to foster a collaborative approach to improving renal service and potentially develop leadership for future improvement and quality initiatives.
Drivers for improvement
The drivers for this project evolved as learning grew and this was supported by Langely et al (2009) who found that developing ideas for delivering change often expand upon reflection
and knowledge. This quality improvement initiative was driven by three primary drivers, which fed the wheels of the secondary drivers and outcomes. These drivers were influenced around the areas of risk which were identified following completion of risk management forms.
1: Restructuring of clinics
There were new renal clinic codes generated by various personnel, due to the designation of new consultants. The multitude of codes confused as it was unclear which code or clinic
should book patients. The impact for patients was the increased likelihood of a clinic not being reconciled, and therefore, no appointment generated for follow up. Also, this resulted in overbooking of the hospital renal clinic, people from different departments booking patients in as desired and frequent “walk-in” patients attending unexpectedly with no medical notes available, again causing a safety concern for patient care.
2: Appointments made
This was the focus on how to ensure that an appointment was generated on the new electronic system called, IPIMS system. Occasionally, renal clinic never deciphered when consultants wanted patients to return, so the outcome was left blank. Attendance at results meetings was inconsistent so decisions were not always clarified.
3: Dedicated administration support
A major gap in the clinic was the lack of administrative support with reliance on the consultant’s secretary or the ward clerk to manage clinics and appointments with no procedure in place to ensure governance.
Measures for patient safety
To determine whether any changes made because of this project could be considered improvements, it was necessary to gather data and review the trend and outcomes objectively. By correlating information over a four-month period, comparing patient attendances with appointments made by the end of the week, it was possible to develop a run chart and ascertain that the changes we implemented were positive and sustainable (Figure 2). Run charts give direction in delivering a change and ascertain if that change is an improvement through visual aid (Institute for Healthcare Improvement 2004).
The information to support the changes and collection of data was generated from the essential tool of a PDSA cycle (Plan-Do-Study-Act), a tool developed by Demming in the 1950s. In planning how to approach the change, carrying out a small test in change, studying the effect of this test and acting on any results, it breaks down the change process and makes success more achievable. The use of this tool was invaluable in breaking down tasks which seemed daunting and making them feel like small steps that could be achieved in a short space of time. By working through the cycle and going back to the drawing board to tweak the process from feedback, sustainable change was facilitated. The PDSA cycle addressed problems from leading a regular blood result meeting and implementing new documentation, to lobbying the CEO for administration support and conducting a team “away day” to address communication.
Results and discussion of project implementation:
The results of this project achieved significant improvements within the renal outpatient clinic. In relation to appointments, while the aim of 100% of patients receiving appointments by the end of the week was not delivered, it was an impressive result of 98%. Patients who did not get return dates however had a clear plan of care, and were likely awaiting a date for surgery, or another procedure. The impact for our department has been cathartic. The knowledge that a system is in place and works to improve patient safety and quality has given a sense of freedom from previous pressures and delivers what is needed in order to move forward as a national service and providing clinical governance and safety for service users.
Staff acknowledged that there was a real safety issue and agreed it needed to be resolved urgently. Through stakeholder mapping, key members of the team were identified who could work together to drive this change for improvement. Working with high interest or high influence members of the team, it was possible to share the ownership of this project so it became personal to staff and those involved in the project overall. Using the PDSA cycle, key members contributed to the development of documentation and clinic process in an inclusive manner through successfully breaking down the steps of change and making tasks more achievable.
As in any team, there are some who resist change, especially some of the consultants who were reluctant to change their practice. This was a barrier that needed to be overcome early in the exercise. The identification of one consultant as a partner in this project was hugely important, both to the success of the improvement initiative and for the initiative instigating practitioner’s self belief and confidence in successfully leading this change initiative.
With support from one consultant, the first team away day was facilitated with communication as a leading topic. This led on to procedures for relaying information, including the importance placed on attending blood result meetings and allowing people time and attention to discuss patient care. The weekly meeting now ensures that all patients who attended the clinic have investigations booked, letters dictated and appointments made. Using new leadership skills, the author now leads this meeting with a clear focus. To highlight the improvements as they were happening, the team were updated weekly regarding data for the previous week and how the trend was progressing. This appealed to some consultants and has fostered a wave of positivity and inclusion among original resisters who see the new energy and want to become part of it. This has brought about a cohesive and collaborative approach and has given rise to suggestions for other areas that can be focused on for change and quality improvement in the future.
Risk management forms were also submitted in order to make the hospital management aware of the safety concerns. This resulted in allocation of a clinic based secretary to manage clinic attendances, which has had a major impact on the service. Another stumbling block was the ability to sustain change when the initiating practitioner, the author, was absent on clinic days at the beginning of this change process, when people went back to old systems and ways of working. This required further use of the PDSA cycle to tweak aspects of document use. Identification of key members of the team who were early adaptors helped to maintain momentum in such absence.
Conclusions and recommendations
This project succeeded on many levels. It achieved an impressive 98% of patients receiving an appointment by the end of the week they attended, up from 64% previously, with a clear and concise plan for all patients and scans or investigations booked as needed. This has resulted in better patient flow and satisfaction from families and staff. Secondly it has improved how the team communicates and sets achievable goals to further develop the service. It has also benefited the author as a project lead, personally, in professional growth and leadership development. People should be aware that the steps in this initiative were small steps. Basic documentation and communication led to its success. No change is too small. Identifying key people and early innovators is vital. By keeping it relevant to the frontline and not complicating the point, people will participate. After presenting this at a Clinical Nurse Specialist meeting, other nurses have approached the author to see what they can take away to their area to improve care. One nurse has also signed up to do the a course on Patient Safety and thus beginning a wider spread of change throughout the organisation.