NETWORK 17
CQI ACTION PLAN-CHANGE CONCEPT #1: Routine CQI Review of Vascular Access
FACILITY:
TEAM MEMBERS:
Medical Director / Nephrologist
CONTACT:
Nurse Department Manager (NDM)
GOAL:
Asst. Nurse Dept. Manager (ADM)
1. To designate a Vascular Access Coordinator who will have allocated time to focus on Vascular Access
Clinical Educator
tracking.
PI Representatives
2. To create/revise a form that contains all the necessary information and can be utilized by all dialysis staff to
Vascular Access Coordinator (VAC)
investigate and track all non-AVF access placements and AVF failures
Facility Nurses
PROBLEM STATEMENT:
Patient Care Technicians
1. The PI Representatives are not solely the Vascular Access Coordinators.
Dietitian
2. There is no complete form that contains all the necessary information that the CQI team as well as the
Social Worker
dialysis staff can input information as pertinent information arise for the investigation and tracking of all nonAVF access placements and AVF failures.
ROOT CAUSE(S):
1. Lack of personnel for the amount of work present.
2. Lack of structure for the vascular access CQI team.
3. Lack of communication between dialysis staff and interdisciplinary team.
ESTIMATED
ACTUAL
RESPONSIBLE
START
COMMENTS
ACTION PLAN
COMPLETION
COMPLETION
TEAM MEMBER
DATE
(STATUS, OUTCOMES, EVALUATION, ETC.)
DATE
DATE
1. Designate a staff
member in the dialysis
facility responsible for
vascular access and
allocate time to focus on
vascular access CQI.
NDM
ADM
Clin. Educ.
PI Rep.
12/28/09
1/22/10
2. Review current form
being used to track
vascular access.
NDM
ADM
PI Rep.
12/18/09
12/28/09
12/18/09
12/28/09
3. Determine the need for a NDM
new form that contains all ADM
the necessary
information and can be
utilized by all dialysis
staff to investigate and
track all non-AVF access
placements and AVF
failures.
NETWORK 17
1. A Staff Nurse 5 Clinical Educator
position has been approved. The
DM and ADM are waiting for a list
of applicants to begin the interview
process. The SN V Clin. Educ. will
be the Vascular Access
Coordinator.
2. There are two vascular access
forms currently being utilized to
track permanent vascular access
placement.
3. Determine if PCTs are reporting
fistula/graft problems to the team
leaders. Determine if the team
leaders in return are following
through and taking appropriate
steps to correct or prevent future
fistula/graft problems.
CQI ACTION PLAN – CHANGE CONCEPT #2 – Timely Referral to Nephrologist
FACILITY:
CONTACT:
GOAL:
1. Patients needing pre-ESRD care are referred to the Nephrologist in a timely manner.
PROBLEM STATEMENT:
1. Patients are not referred timely to the Nephrologist for pre-ESRD care.
ROOT CAUSE(S):
1. Lack of compliance with education material provided to primary care physicians and clinicians by the
nephrologist.
2. Limited multi-disciplinary approach to pre-ESRD care.
ACTION PLAN
RESPONSIBLE
TEAM MEMBER
START
DATE
ESTIMATED
COMPLETION
DATE
ACTUAL
COMPLETION
DATE
TEAM MEMBERS:
Hospital Medical Director
Primary Care Physicians
Physician Extenders (NP, PA)
Medical Director / Nephrologist
CKD Clinic Nurse
CKD Clinic Medical Assistant
Nurse Department Manager (NDM)
Asst. Nurse Dept. Manager (ADM)
PI Representatives
Vascular Access Coordinator (VAC)
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
1. Encourage PCPs to
utilize ESRD/CKD
referral criteria to
ensure timely referral of
patients to the
nephrologist.
2. CKD clinic RN/MA to
support nephrologist to
document AVF plan for
all patients expected to
require renal
replacement therapy.
Hosp. Medical
Director
Nephrologist
1/4/10
2/26/10
1. Hospital Medical Director and
Nephrologist to present the
importance of early referral to
various committees where PCPs,
house staff and attending
physicians are in attendance.
2. NDM to meet with Ambulatory Care
Services (ACS) Director to discuss
CKD Clinic RN and/or MA
responsibility.
Nephrologist
NP, PA
ACS Director
CKD Clinic RN
CKD Clinic MA
NDM
ADM
PI Rep.
VAC
1/7/10
1/22/10
3. Coordinate with CKD
clinic RN/MA to educate
patients and family on
benefits of AVF and to
protect vessels.
NDM
ADM
PI Rep.
VAC
Clin. Educ.
1/7/10
1/22/10
3. NDM to meet with Ambulatory Care
Services (ACS) Director to discuss
CKD Clinic RN and/or MA
responsibility.
4. Consider using a
Hospital
1/4/10
2/26/10
4. Hospital Medical Director and
physician extender (NP,
PA) to provide vascular
access education,
referral, and support in
the CKD clinic.
Medical
Director
Nephrologist
ACS Director
NDM
ADM
PI Rep.
VAC
Clin. Educ.
Nephrologist will meet with ACS
Director to discuss physician
extender responsibility.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT #3
– Early Referral to Surgeon for “AVF only” Evaluation and Timely Placement
FACILITY:
CONTACT:
GOAL:
1. Patients needing pre-ESRD care are referred to the Nephrologist in a timely manner.
PROBLEM STATEMENT:
1. Patient not referred to surgeon timely for “AVF only” evaluation and placement.
ROOT CAUSE(S):
1. Limited or no patient pre-ESRD care.
2. Lack of structured referral system.
3. Lack of nephrologist-surgeon partnership.
ACTION PLAN
RESPONSIBLE
TEAM MEMBER
START
DATE
ESTIMATED
COMPLETION
DATE
1. Support nephrologist /
nurse to perform
appropriate evaluation
and exam prior to
surgeon referral before
dialysis or within 90 days
of HD start.
Nephrologist
ACS Director
NDM
ADM
CKD Clinic RN
CKD Clinic MA
VAC
Clin. Educ.
1/7/10
1/22/10
2. Support nephrologist to
refer patient for vessel
mapping prior to surgeon
referral before dialysis or
within 90 days of HD
start.
3. Support nephrologist to
refer to surgeon for “AVF
only” no later than Stage
IV, GFR <30.
4. Support nephrologist to
define expectations to
surgeon, including vessel
mapping.
2-4.
Nephrologist
NDM
ADM
VAC
Clin. Educ.
Social Worker
1/7/10
1/22/10
5. If pre-dialysis AVF
Hospital
1/4/10
ACTUAL
COMPLETION
DATE
TEAM MEMBERS:
Hospital Medical Director
Physician Extenders (NP, PA)
Medical Director / Nephrologist
CKD Clinic Nurse
CKD Clinic Medical Assistant
Nurse Department Manager (NDM)
Asst. Nurse Dept. Manager (ADM)
PI Representatives
Vascular Access Coordinator (VAC)
Social Worker
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
1. NDM to meet with Ambulatory Care
Services (ACS) Director to discuss
CKD Clinic RN and/or MA
responsibility.
3-4. Customize referral letters to
surgeons for “AVF only “evaluation and
placement.
2/26/10
5. Hospital Medical Director and
placement does not
occur, support
nephrologist and/or
house staff to order AVF
evaluation and placement
at initial hospitalization for
HD start.
Medical
Director
Nephrologist
NDM
ADM
VAC
Clin. Educ.
Social Worker
Nephrologist to present AVF evaluation
and placement to various committees
where house staff and attending
physicians are in attendance.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 4
-Surgeon selection based on best outcomes, willingness, and ability to provide access services
FACILITY:
CONTACT:
GOAL:
1. Patients are referred to surgeons with best outcomes for AVF placement.
PROBLEM STATEMENT:
1. Surgeon referral and selection not based on best AVF outcomes.
ROOT CAUSE(S):
1. Limited surgeon referral sources.
2. Limited surgeon education and/or experience with AVF procedures.
3. Surgeon referral based upon facility preferences.
ACTION PLAN
RESPONSIBLE
TEAM MEMBER
START
DATE
ESTIMATED
COMPLETION
DATE
1. Support nephrologist to
Hospital
communicate
Medical
expectations to surgeons
Director
performing vascular
Nephrologist
access.
ACS Director
NDM
ADM
CKD Clinic RN
CKD Clinic MA
VAC
Social Worker
1/4/10
2/26/10
2. Support nephrologist to
refer to surgeons willing
and able to meet the
standards and
expectations.
1/7/10
1/22/10
Nephrologist
NDM
ADM
Clin. Educ.
VAC
PI Reps.
TEAM MEMBERS:
Hospital Medical Director
Vascular Surgeons
Medical Director / Nephrologist
CKD Clinic Nurse
CKD Clinic Medical Assistant
Nurse Department Manager (NDM)
Asst. Nurse Dept. Manager (ADM)
PI Representatives
Vascular Access Coordinator (VAC)
Social Worker
ACTUAL
COMPLETION
DATE
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
1. Hospital Medical Director and
Nephrologist to present AVF
evaluation and placement to various
committees where house staff and
attending physicians are in
attendance. Customize referral
letters to surgeons for “AVF only
“evaluation and placement.
Hospital Medical Director and
Nephrologist to present AVF
evaluation and placement to various
committees where surgeons are in
attendance. NDM to meet with
Ambulatory Care Services (ACS)
Director to discuss CKD Clinic RN
and/or MA responsibility.
2. Create referral letter.
3. Evaluate surgeon
selection on frequency,
quality and patency of
access placement.
4. Conduct data collection
ongoing at dialysis
facility on surgeon
procedures performed
and results. Report data
monthly at CQI meeting.
VAC
PI Reps.
1/4/10
Ongoing
3. Create audit tool.
VAC
PI Reps.
1/4/10
Ongoing
4. Create audit tool and include data in
monthly CQI meeting.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 5
- Full range of appropriate surgical approaches to AVF evaluation and placement
FACILITY:
TEAM MEMBERS:
Vascular Surgeons
CONTACT:
Medical Director / Nephrologist
GOAL:
Nurse Department Manager (NDM)
1. All attempts/approaches to AVF evaluation and placement are made.
Asst. Nurse Dept. Manager (ADM)
PROBLEM STATEMENT:
1. Surgical approaches offered by surgeon/dialysis facility are limited; patients are not considered candidates for PI Representatives
Vascular Access Coordinator (VAC)
AVF
Hospital Unit Clerk
ROOT CAUSE(S):
1. Limited education/experience of surgeon
2. Limited surgeon referral source.
3. Limited resources/locations for surgeon to expand techniques offered.
ESTIMATED
ACTUAL
RESPONSIBLE
START
COMMENTS
ACTION PLAN
COMPLETION
COMPLETION
TEAM MEMBER
DATE
(STATUS, OUTCOMES, DISPOSITION, ETC.)
DATE
DATE
1. Provide education to
surgeon through
CD/DVD and/or
mentorship available
from network, i.e.
expanded surgical
procedures and patient
criteria eligible for AVF.
2. Ensure venous mapping
is completed for all
patients needing
permanent vascular
access.
Nephrologist
Vascular
Access
Coordinator
Clin. Educ.
PI Reps.
1/4/10
2/26/10
1. Obtain and reproduce educational
material.
Nephrologist
NDM
ADM
Clin. Educ.
Vascular
Access
Coordinator
PI Reps.
HUC
3. Partner nephrologist,
Nephrologist
facility vascular access
Surgeon
coordinator, and surgeon VAC
to evaluate current AVG PI Reps.
patients for secondary
AVF.
4. Send facility comparative VAC
1/4/10
Ongoing
2. Review records of all patients still
needing permanent vascular
access.
1/4/10
Ongoing
3. Review of patients who currently
have AVG.
1/4/10
Ongoing
surgeon data to
surgeons not performing
expanded techniques.
(i.e. vein transposition).
PI Reps.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 6 – Secondary AVF placement in patients with AV Grafts
FACILITY:
CONTACT:
GOAL:
1. Patients with AVG are identified for potential placement of AVF.
PROBLEM STATEMENT:
1. Patients are not properly evaluated for possible secondary AVF.
ROOT CAUSE(S):
1. Higher successful placement of AVG.
2. Surgeon preference for placing AVG.
ACTION PLAN
1. Support nephrologist and
vascular access
coordinator to evaluate
every AVG patient for
possible secondary AVG
placement.
2. Educate dialysis staff and
vascular access
coordinator to examine
outflow vein of all AVG
patients during dialysis
treatments at least
monthly. Identify patients
who may be suitable for
elective secondary AVG
conversion in upper arm
and notify nephrologist of
patient list.
3. Support nephrologist to
refer eligible patients to
surgeon before AVG
failure.
4. Document vascular
access plan of care for all
patients currently using a
graft for dialysis.
RESPONSIBLE
TEAM MEMBER
Nephrologist
Vascular
Access
Coordinator
Primary RNs
Clin. Educ.
Vascular
Access
Coordinator
PI Reps.
Nephrologist
Vascular
Access
Coordinator
Primary RNs
Primary RNs
VAC
START
DATE
TEAM MEMBERS:
Medical Director / Nephrologist
PI Representatives
Vascular Access Coordinator (VAC)
Primary Nurses
ESTIMATED
COMPLETION
DATE
1/4/10
Ongoing
1/4/10
Ongoing
1/4/10
Ongoing
1/4/10
Ongoing
ACTUAL
COMPLETION
DATE
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
1-3. Ongoing assessment of patients
with AVG.
4. Monthly Primary Nurse
responsibility.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 7 – AVF Placement in Patients with Catheters where Indicated
FACILITY:
TEAM MEMBERS:
Medical Director / Nephrologist
CONTACT:
PI Representatives
GOAL:
Vascular Access Coordinator (VAC)
1. Decrease the occurrence of patients with catheters and facilitate the placement of AVFs in this population.
Primary Nurses
PROBLEM STATEMENT:
Clinical Educator
1. Facility has high occurrence of catheters.
Hospital Registration
ROOT CAUSE(S):
1. High catheter placement for prevalent and/or incident patients.
2. Limited time prior to dialysis for nephrologist and/or surgeon referral.
3. Patient preference.
4. Patient insurance coverage/status.
5. Lack of patient education.
ESTIMATED
ACTUAL
RESPONSIBLE
START
COMMENTS
ACTION PLAN
COMPLETION
COMPLETION
TEAM MEMBER
DATE
(STATUS, OUTCOMES, DISPOSITION, ETC.)
DATE
DATE
1. Evaluate all catheter
patients for AVF,
regardless of previous
access. Include vein
mapping in evaluation.
2. Implement protocol to
track all catheter
patients for removal of
catheter.
3. Investigate and track all
catheter placements
monthly and report to QI
team.
4. Document vascular
access plan of care for
all patients currently
using a catheter.
5. Educate and follow up
with catheter patients
monthly to support
placement of permanent
vascular access.
Nephrologist
VAC
PI Reps.
Primary RNs
Ongoing
Ongoing
1. Primary RNs to include
evaluation in monthly progress
notes.
VAC
PI Reps.
Primary RNs
1/18/10
2/1/10
2. Create protocol to track all
catheter patients for removal of
catheter.
VAC
PI Reps.
Ongoing
Ongoing
VAC
Primary RNs
Ongoing
Ongoing
3. Utilize Fistula First Data
Collection Tool to track catheter
placements and report to QI
team.
4. Primary RNs to document
vascular access plan of care in
the monthly progress notes.
Clin. Educator
VAC
PI Reps.
Primary RNs
1/18/10
Ongoing
5. Schedule monthly classes to
educate patients and provide
support for placement of
vascular access.
6. Track insurance
VAC
1/18/10
Ongoing
6. Hospital registration to provide
coverage/status and
PI Reps.
determine steps needed Social Worker
to obtain full scope
Hospital
coverage.
Registration
dialysis unit with an updated list
of insurance coverage.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 8 – Cannulation Training for AV Fistulas
FACILITY:
TEAM MEMBERS:
Medical Director / Nephrologist
CONTACT:
PI Representatives
GOAL:
Vascular Access Coordinator (VAC)
1. More training on AVF and AVG cannulation will be provided to the staff.
Clinical Educator
PROBLEM STATEMENT:
Charge Nurses
1. Staff has limited continuous cannulation training and the best teaching tools are not used/available.
Social Worker
ROOT CAUSE(S):
1. There is no consistent scheduling of best cannulators on both patient shifts.
2. Staff has limited exposure to AVG or AVF cannulation needs due to high occurrence of catheters.
3. Limited or sub-optimal surgical technique.
ESTIMATED
ACTUAL
RESPONSIBLE
START
COMMENTS
ACTION PLAN
COMPLETION
COMPLETION
TEAM MEMBER
DATE
(STATUS, OUTCOMES, DISPOSITION, ETC.)
DATE
DATE
1. Identify and use the
best cannulators and
best teaching tools (e.g.
videos, dummy fistula
arm) to teach AVF
cannulation to all
appropriate dialysis
staff. Provide
cannulation training on
a continuous basis.
2. Implement protocol for
initial dialysis
treatments for new
AVFs and assign the
most skilled staff to
such patients.
3. Create a selfcannulation program
and offer the option of
self-cannulation to
patients who are
interested and able.
NDM
ADM
Clin. Educ.
VAC
2/1/10
Ongoing
1. Obtain best teaching tools and
schedule cannulation training on
a regular basis.
NDM
ADM
Clin. Educ.
VAC
Charge Nurses
2/1/10
Ongoing
2. Review protocol for initiating
dialysis treatment on new AVFs.
Adjust schedule as necessary to
schedule skilled staff on the shift
of patients with new AVFs.
NDM
ADM
Clin. Educ.
VAC
Social Worker
2/1/10
2/22/10
3. Create a course outline for a
self-cannulation program.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 9 – Monitoring and Maintenance to Ensure Adequate Access Function
FACILITY:
CONTACT:
GOAL:
1. More training on AVF and AVG cannulation will be provided to the staff.
PROBLEM STATEMENT:
1. Inadequate monitoring and surveillance to ensure adequate vascular access function.
ROOT CAUSE(S):
1. Limited staff experience and/or knowledge with vascular access monitoring technique.
2. Lack of protocols in place for monitoring and surveillance of vascular access.
3. Lack of appropriate use of data collected from vascular access surveillance.
4. Lack of multi-disciplinary approach to vascular access surveillance and monitoring.
ESTIMATED
ACTUAL
RESPONSIBLE
START
ACTION PLAN
COMPLETION
COMPLETION
TEAM MEMBER
DATE
DATE
DATE
1. Support nephrologist
and surgeon to conduct
post-operative exam of
AVF at 4 weeks to
detect early signs of
failure and refer for
interventions as
needed.
2. Adopt standard
procedures for
monitoring, surveillance,
and timely referral if
indicated in the dialysis
facility.
3. Support nephrologist
and surgeons to adopt
standard criteria to
determine the
appropriate extent of
intervention on existing
access before placing
new access.
4. Develop vascular
access plan of care for
TEAM MEMBERS:
Medical Director / Nephrologist
Surgeon
NDM
ADM
Clinical Educator
PI Representatives
Vascular Access Coordinator (VAC)
Primary Nurses
QI Team
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
Nephrologist
Surgeon
NDM
ADM
VAC
PI Reps.
1/4/10
Ongoing
Nephrologist
NDM
ADM
Clin. Educ.
VAC
1/4/10
Ongoing
2. Formulate monitoring
procedures.
Nephrologist
Surgeon
NDM
ADM
Clin. Educ.
VAC
1/4/10
Ongoing
3. Create standard criteria.
QI Team
Primary RN
Ongoing
Ongoing
4. Primary RNs to document
vascular access plan of care in
every patient integrating
facility, nephrologist,
and surgeon.
VAC
monthly progress notes.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 10 – Education for Care Givers and Patients
FACILITY:
CONTACT:
GOAL:
1. Improve vascular access outcomes as a result of increased staff, patient and family knowledge on caring for
access.
PROBLEM STATEMENT:
1. Poor vascular access outcome due to lack of caregiver/patient knowledge on caring for access.
ROOT CAUSE(S):
1. Limited pre-ESRD education
2. Limited patient education program in CKD clinic and/or dialysis facility.
3. Limited resources for patients and caregivers.
ACTION PLAN
1. In-service facility staff
regularly on vascular
access and patient
talking points.
2. Provide education to all
caregivers pre-dialysis
and after HD start,
integrating the
nephrologist and
surgeon into education
sessions.
3. Educate patients to
improve the quality of
their vascular access
outcome through
knowledge of prepping
sites, applying pressure
at sites, use of clamps,
assisting staff to select
sites, etc.
RESPONSIBLE
TEAM MEMBER
START
DATE
ESTIMATED
COMPLETION
DATE
ACTUAL
COMPLETION
DATE
TEAM MEMBERS:
Medical Director / Nephrologist
Surgeon
NDM
ADM
Clinical Educator
PI Representatives
Vascular Access Coordinator (VAC)
Primary Nurses
Facility Nurses
Patient Care Technicians
Dietitian
Social Worker
CKD Clinic Nurses/MA
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)
Clin. Educ.
PI Reps.
Social Worker
2/15/10
Ongoing
1. Schedule monthly in-services for
staff.
Nephrologist
Surgeon
Clin. Educ.
PI Reps.
Social worker
Dietitian
2/15/10
Ongoing
2. Schedule meetings with patients
and caregivers before and after
initial HD treatments.
Nephrologist
Clin. Educ.
PI Reps.
Social Worker
Patient Care
Technicians
2/15/10
Ongoing
3. Schedule regular educational
opportunities to patients
regarding vascular access.
NETWORK 17
CQI ACTION PLAN – CHANGE CONCEPT # 11 – Outcomes Feedback to Guide Practice
FACILITY:
CONTACT:
GOAL:
1. Implement the review of data monthly or quarterly in QI and staff meetings.
PROBLEM STATEMENT:
1. Facility outcomes not used to guide future practice with vascular access.
ROOT CAUSE(S):
1. Lack of structure to review outcomes and make system changes.
2. Lack of system to collect vascular access data.
3. Limited analysis of data collected.
ESTIMATED
RESPONSIBLE
START
ACTION PLAN
COMPLETION
TEAM MEMBER
DATE
DATE
1. Review quarterly
vascular access data
received from network
and report at CQI
meetings.
2. Collect and review
surgeon vascular
access placements,
quality and quantity,
and report at CQI
meetings.
3. Report data at staff
meetings routinely.
4. From analysis of data in
CQI, document next
steps to making
changes in facility.
Nephrologist
NDM
ADM
PI Reps.
VAC
Nephrologist
VAC
PI Reps.
NDM/ADM
VAC/PI Reps.
NDM
ADM
VAC
PI Reps.
Ongoing
Ongoing
Ongoing
Ongoing
1/27/10
Ongoing
3/1/10
Ongoing
TEAM MEMBERS:
Medical Director / Nephrologist
Surgeon
NDM
ADM
Clinical Educator
PI Representatives
Vascular Access Coordinator (VAC)
Primary Nurses
ACTUAL
COMPLETION
DATE
COMMENTS
(STATUS, OUTCOMES, DISPOSITION, ETC.)