Running head: JOURNAL POST 2 1

Journal Post 2

Elaine Dean

Jacksonville University

January 31, 2018

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Journal Post 2

Project Overview 1/22/2018

There were a lot of activities this week including meetings with the interdisciplinary

team, frequent discussions with my preceptor, site visits and research. However, the highlight of

my week was my visit to the Florida Medical Quality Assurance Department (FMQAI), which

housed a department focused on dialysis related issues. FMQAI assist the Centers for Medicare

and Medicaid to improve the quality and safety of dialysis services by partnering in quality

improvement with nephrology practitioners, dialysis centers, patients, and stakeholders.

Barriers/Frustrations

I spent a lot of time this week with the new peritoneal dialysis RN and the crownweb

administrator. We brainstormed on how to establish an excel spreadsheet for data collection and

outlined six measures we would target. They are peritoneal dialysis adequacy, nutritional status,

mineral and renal bone disease, anemia management, vaccination, and infection control.

However, we found out quickly that we had to search multiple layers of progress notes to find

data as it was not centrally located and tracked in a QAPI program. In light of this finding, we

requested that for the upcoming month of February all pertinent lab values be collected on all the

patients to establish a baseline. The request was forwarded to the chief nephrologist and we are

awaiting a response.

Surprises

The main surprise of this week was the policy. I reviewed the policy and found that not

only had it expired it lacked significant elements that should be monitored. And while there is an

up-to-date policy for hemodialysis the peritoneal dialysis policy needed a lot of work. In

addition, a switch was just made in the model of the machine used to the Baxter Amia cycler and
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this caused a significant drop in dialysis adequacy among several patients due to machine

malfunction, so much so that the chief of nephrology had to threaten to return all the machine

back unless the company corrected the problem. This disrupted care and caused several

admissions due to uremia.

Professional Development

I was invited by the dialysis team to participate in their unit-based council meeting. I

gained valuable experience in engaging and leading a team. The VA encourages the shared

governance model, this reflects nursing values and exemplify the culture of the organization. The

dominant attributes are nursing empowerment, nursing autonomy, and cost-effective quality

care. My contribution to the meeting was to challenge the team to determine a professional

practice model for the unit. For example, Watson’s Theory of Caring. This would align with the

relationship-based care as a care delivery model. The nurses committed to designing structures

and processes that would optimize and support elements of care which include unit organization,

staff member role, communication tools, patient and family education, documentation, and unit

governance.

Self-Growth Assessment

I gained skills in autonomous nursing practice, participative management, collaborating

with the interdisciplinary team, the practice of transformational leadership, explored gaining

control over nursing practice, leading practice changes, exemplifying evidence-based practice,

and showing colleagueship.

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Project Goals Met

Demonstrate ethical obligations in a manner consistent with high-quality nursing

practice. Clearly represent self with respect to name, title, and role within the boundaries of the

nursing practicum role.

Propose a conceptual framework based on nursing theory and research to ensure that the

quality of kidney care delivered to veterans meet or exceeds the accepted national standards of

practice by aligning VA dialysis policy to meet community dialysis standards stipulated by

CMS.

Program Objectives Met

Use ethical principles ethical principles and critical decision-making skills to function as

a leader and advocate within healthcare systems.

Appraise theories and conceptual framework from nursing and related discipline as a

foundation for implementing change in nursing and applies research outcomes within practice.

Detailed Project Plan

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The Plan-Do-Study-Act (PDSA cycle) will be the model used for the development of this

Quality Assurance and Performance Improvement (QAPI) toolkit. It is the recommended model

for performance improvement in dialysis care.

Plan

The planning component of this project had four (4) components.

Problem Statement: the peritoneal dialysis (PD) program has no established QAPI tool.

Focusing on the peritoneal dialysis patient there should be an ongoing comprehensive data-

driven Quality Assurance and Performance Improvement (QAPI) plan. The QAPI program

should include indicators related to improved health outcomes such as nutritional status, mineral

and renal bone disease, anemia management, infection control, vaccination, and dialysis

adequacy.

Determine the Scope: the scope of the QAPI program will be facility-wide and include

reviews of all services provided; in-center, home peritoneal dialysis, and self-care.

Establish Performance Objectives: What is to be accomplished – Develop and establish

a QAPI toolkit for peritoneal dialysis.

The SMART criteria will be used to write the performance improvement plan

(SPECIFIC, MEASURE, ACHIEVE, RESULT FOCUS & TIMEFRAME).

Timeframe: By March 2, 2018, a QAPI toolkit will be created with clearly defined

activities so the staff can skillfully perform their jobs and improve patient outcome by meeting

performance improvement (PI) goals and ultimately improve quality of care.

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Do

Implement intervention. Each intervention will have a timeframe and designated

personnel. This stage also involves the collection of data, data analysis, tabulation of data, and

documentation.

STUDY

Examine results and re-evaluate with the team. Is the process working? If not, why not?

What is working well? If necessary, re-evaluate the root causes/barriers as well as interventions.

Document progress, findings, and perform revisions in goals and interventions.

Act

If the goals are not met, begin a new plan or a revision of the existing plan. If the goals

are met it is time to expand to another problem.

Current Stage of the Project

The project is currently in the DO Stage. I have collaborated with the team and we looked

at ways to effectively and efficiently collect data. As a group, we decided on an excel program

with data typed directly into the fields. The sheets can also be printed for manual entry of

information. We are also working on trying to get the information to auto-populate into a graph

for data comparison.

Literature Review

Objectives: to review the current literature on quality assurance and performance

improvement (QAPI). QAPI is becoming increasingly relevant with the advent of value-based

care that ties quality to payments.

Design: A review of the literature

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Data Source: Electronic searches of the CINAHL and Cochrane Library database using

terms such as peritoneal dialysis, quality improvement, performance improvement, KDOQI

guidelines and Orem’s Theory. Full-text articles were retrieved and relevant data extracted and

synthesized.

Results: Most of the articles focused on education intervention programs for peritoneal

dialysis. Findings on the link between the training received on peritoneal dialysis and peritonitis

rates among individuals undergoing peritoneal dialysis were inconsistent (whittle & Black,

2014). Peritoneal dialysis learners should be taught self-management skills as well as technical

skills. They might also benefit from receiving decision-making aids. Older people, people with

co-morbidities and individuals with low educational status need additional time to acquire self-

care skills and are more likely to develop peritonitis. Frequent and consistent home visits have

the ability to improve quality and learning outcome. Peritoneal dialysis patients learning needs

should be assessed and addressed appropriately. Management of other chronic disease processes

such as diabetes and hypertension have shown to have a positive outcome for individuals

receiving peritoneal dialysis. As part of a continuous quality improvement program, the

incidence of peritonitis should be consistently monitored. It may even be useful to monitor any

peritonitis episodes that occur after Tenckhoff catheter insertion and before PD training starts. In

addition the overall peritonitis rate, monitoring should include peritonitis rate of specific

organisms and drug susceptibilities of the infecting organism. With this information,

interventions can be implemented when peritonitis rates rising or unacceptably high.

Conclusion: Educational intervention is a successful component of peritoneal dialysis.

However, in reviewing the literature peritoneal dialysis QAPI appears to be an understudied area

despite the potential these measures have to make this therapy more successful. As it stands
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CMS requirement is a KT/V of 1.7 (adequacy rate) for peritoneal dialysis. On the other hand,

there are multiple QAPI measures for hemodialysis. For now, further research is needed on

QAPI in PD. In the meantime, some of the QAPI measures for hemodialysis can provide

guidance for peritoneal dialysis.

Week 4 1/29/2018

This is the fourth week of my practicum project. It was a mixture of highs and lows. I did

extensive research on peritoneal dialysis, QAPI. However, I found that a lot of my information

came more so from the International Society for Peritoneal Dialysis (ISPD), National Kidney

Foundation NKF), Kidney Disease Outcome Quality Initiative (KDOQI), CMS, the MAT, QIP,

and FMQAI. I could not find a lot of full-text articles that actually addressed QAPI completely

but each article would address individual aspects. I also enjoy watching the clinical team use the

new Baxter Amia machine, this was an exciting experience for me because I love the clinical

setting. This new machine has a share source connectivity platform that provides a two-way

connection between the cycler and the clinician. Treatment data is automatically sent to the

clinic, giving clinicians the ability to identify, manage, and even adjust treatment remotely. It is

also voice guided to walk the patient through detailed instructions and has a touch screen with

graphics and animation. This week I also worked on the design and presentation of the QAPI

spreadsheet.

Barriers/Frustrations

We got a response from the chief of nephrology regarding obtaining lab values on all the

patients as a baseline. She did not want this to be done. We were also advocating for monthly

kt/v (dialysis adequacy as measured by urea clearance) instead of quarterly. Our rationale was

that we would be able to determine adequacy issues earlier before the patient progresses to
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uremia. However, she did not want the schedule changed. So, I performed my research thinking I

could use research to change her mind. What I found is that the NKF KDOQI clinical practice

guidelines recommend kt/v to be measured the first month after the start of dialysis then at least

every four months. The nephrology chief felt that since the kt/v is based on a 24-hour urine

collection it would be too technically taxing on some of our patients to acquire monthly kt/v

Self-Growth Assessment

So far I think I am making strides with the practicum project. I am finding that it involves

a lot of research and collaborating. This week I had to learn to deal with situations that are

beyond my control, accept setbacks and find creative ways to possibly achieve the same

outcome.

Professional Development

This week my preceptor also served as my mentor as I started to hit some bumps in the

road. As a veteran Nurse Practitioner in nephrology, she had valuable insights. Her extensive

knowledge and experience helped me to gain a fresh perspective and insight into the goal of the

project and its importance. I am learning the value of a support system where I am able to seek

feedback and guidance, exchange ideas, and vent at times.

Project Objectives Met

Use the Measure Assessment Tool (MAT) which list the expected outcome based on

community-accepted standards and values as a reference and for further research in the

development of the peritoneal dialysis toolkit

Design, implement and establish a QAPI toolkit for peritoneal dialysis by utilizing the

most recent MAT as well as measures from the end-stage renal disease (ESRD) quality

improvement program (QIP).

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Program Objective Met

Apply health information technologies to increase health literacy and enhance the direct

and indirect care of patients

Design nursing strategies to solve clinical problems and improve patient care through the

integration of knowledge from practice, theory, and research.

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(APA Purpose of Study Methods Study Results Practice

Reference) Implications

O’Shaughnessy, To provide an Literature Orem’s Theory The nursing

M. (2014). overview of the Review of Self-Care agency will
Application of use of Orem’s can be adapted support the
Dorothea Theory of Self- into the home patient to
Orem’s theory Care to guide the based therapy meet self-care
of self-care to care for elderly dialysis setting, needs,
the elderly patients on The integration facilitate
patient on peritoneal of patient decision-
peritoneal dialysis centered care, making and
dialysis. high quality independence.
Nephrology patient A sense of
Nursing education, autonomy will
Journal, 41(5) implementation promote
of emotional positive
and supportive health
measures and outcome and
assessment of adjustments to
the patient changing
cognitive and quality of life
physical needs.
abilities can
empower the
process of self-
care.
Kazancioglu, To review the Literature Each PD Teamwork is
R. (2013). available Review program need the key with
Improving the literature on the to identify its the patient
quality of a development and special being central
peritoneal evaluation of PD circumstances, to all
dialysis service: programs and to deficiencies endeavors.
Learning from provide and strong
experience recommendations points, and
then strategize
accordingly for
for a successful
outcome
Whittle, A., Benchmarking A quality A structured,
Black, K. infection rates for improvement quality
(2014). peritoneal process improvement
Improving dialysis approach is
outcome in beneficial for
peritoneal ongoing PD
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dialysis exit site programs.

care. Renal Continuous
Society of monitoring of
Australasia outcome
journal, 10(3), against a
126-132 benchmark is
essential to
any unit’s
quality
improvement
program.
Rotsukon, V., Examines the A literature In order to Focused need
Sindhu, S. challenges of PD review maximize PD to be placed
(2014). “Lets care delivery effectiveness on
keep close”: healthcare transformative
Increasing providers roles for PD
peritoneal should address care from
dialysis service four practical provider-
effectiveness solutions: oriented to
through timely problem patients’ self-
bridging the gap identification, managed care
between patient effective PD
and provider. training,
Renal Society continuing
of Australasia home visits and
Journal, 11(2) support and
standardization
of clinical
practice
processes used.
Schreiber, M. L. To review the Literature The education PD nurses
(2016). selection and Review of nursing play a key
Peritoneal preparation staff, caregiver, role in
dialysis: process for PD; and patient is educating
Understanding, PD catheters and vital. The patients and
education and systems; the training and caregivers
adhering to importance of approach must regarding PD,
standards. infection be tailored to including
MedSurg prevention with the education process
Nursing, 25(4) emphasis on level and guidelines and
catheter site care learning needs the need to
and peritonitis. of the patient adhere to
and care giver. appropriate
Infection techniques
prevention is
paramount.
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References

Balasubramaniyam, R., Nirmala, V. R., Yogesh, V., Sethuraman, R., Devi, S. B., Balakrishnam,

N. M., & Bakthavathsalam, G. (2013). Comparison of peritoneal transport characteristics

at second week and at six months of peritoneal dialysis commencement. Indian Journal

of Nephrology, 23(5).

Figueiredo, A. E., Bernardini, J., Bowers, E., Hiramatsu, M., Price, V., Su, C., ... Brunier, G.

(2016). ISPD Guidelines/Recommendations. Peritoneal Dialysis International, 36, 592-

609.

Kazancioglu, R. (2013). Improving the quality of a peritoneal dialysis service: Learning from

experience. Journal of Renal Care, 39(1), 42-49.

Lam, L. W., Lee, D. T., & Shiu, A. T. (2013). The dynamic process of adherence to a renal

therapeutic regimen: Perspectives of patients undergoing continuous ambulatory

peritoneal dialysis. International Journal of Nursing Studies, 50, 908-916.

National Kidney Foundation. (2017). Kidney Disease Outcome Quality Initiative: Peritoneal

dialysis targets and measurements. Retrieved from http://kidney.org

O’Shaughnessy, M. (2014). Application of Dorothea Orem’s theory of self-care to the elderly

patient on peritoneal dialysis. Nephrology Journal of Nursing, 41(5).

Schreiber, M. (2016). Peritoneal dialysis: Understanding, educating, and adhering to standards.

MedSurg Nursing, 25(4).

Whittle, A., & Black, K. (2014). Improving outcome in peritoneal dialysis exit site care. Renal

Society of Australasis Journal, 10(3), 126-132.