Improving Identification, Management of CKD in Primary Care
Improving Identification, Management of CKD in Primary Care
The first step involved establishing an expert faculty to review the evidence on CKD and agree the scope and aims of the collaborative. The faculty included clinical staff from primary and secondary care, patient representatives and individuals with expertise in improvement. Two overarching objectives were established: to halve the gap between recorded and estimated prevalence and to ensure that 75% patients with recorded CKD had their BP managed according to the targets recommended in national guidelines (<140/90 for patients without proteinuria; <130/80 for patients with proteinuria). BP management was identified as the measure reflecting the overall quality of CKD care as it links to progression of CKD and cardiovascular outcomes.
Nineteen practices from four administrative areas within Greater Manchester took part in Phase 1. The project budget was sufficient to support involvement of 4–5 practices per area (representing 7–10% of the practice population). Practices were recruited by a mix of self-selection following advertisement of the initiative and nomination by local NHS managers. Recruited practices represented different sizes (as measured by patient 18+ list size, range 1671–9974) and adult CKD prevalence at baseline (range 1.5–5.9%). Once enrolled, practices were invited to the first of three joint learning events. Each practice was encouraged to send three staff members who would form the practice improvement team. To reflect the multi-disciplinary nature of the project, it was suggested that the improvement team should include General Practitioner, nursing and administrative representation. The first learning event introduced the improvement collaborative methodology, CKD guidelines and improvement targets for the collaborative. Subsequent learning events addressed issues such as building effective improvement teams, creating a receptive context for change and sustaining improvements in practice. Between the learning events, improvement teams were expected to test and apply planned changes using PDSA cycles. Two facilitators made regular practice visits to support the improvement process and provide help with activities such as data searches, managing practice registers, developing process maps and advising on how to overcome particular barriers or problems. This latter activity was informed by an initial assessment of the practice context to identify factors that could facilitate or impede improvement, for example, the way in which the practice was usually run, issues of leadership and culture, the level of teamwork and communication.
All practices were required to submit monthly data relating to the numbers of patients on the CKD register, numbers tested for proteinuria and the number of patients with BP managed to target. These data were analysed by the project team and reported back to practices on a monthly basis in the form of run charts, which presented progress against the key indicators over time both for their own practice and the collaborative as a whole. This allowed individual practices to benchmark progress against their peers; it also enabled the improvement facilitators to identify areas where more targeted input and support was required.
At project inception stakeholder input had indicated that uptake of the improvement programme would only be possible with staff time reimbursement. As part of the implementation strategy, therefore, practices received financial resources to secure protected time for improvement teams; different practices spent this in different ways including locum doctor cover to release physicians for improvement work and buying additional hours from practice staff. In addition in Phase 1, a small additional per patient payment was made for completing key stages of the improvement process (baseline data collection and attendance at the three learning sessions).
At the end of Phase 1, a closing meeting was held to share the experiences and successes of the participating practices. The facilitation team also reflected on the learning gained during the collaborative, informed by the formative evaluation that had been ongoing throughout the implementation process (and which is detailed more fully in the following section). This led to the development of a CKD improvement guide, which summarized the key activities involved in implementation: creating a foundation for improvement, identifying patients with CKD, achieving optimal management of patients with CKD and ensuring improvements are sustained. This guide, complete with accompanying resources and links to other useful available information, was made available as an online resource. It also led to discussions with a CLAHRC initiative in another region of the country that had been involved in developing a data extraction and audit tool to analyse practice registers in relation to patients with CKD. The two CLAHRCs agreed to collaborate to develop a programme known as IMPAKT− (IMproving Patient care and Awareness of Kidney disease progression Together).
The IMPAKT™ tool formed a central part of the evidence and implementation resource for Phase 2 of the improvement collaborative. Other changes from Phase 1 included the appointment of a practice nurse from one of the practices that had been involved in the Phase 1 collaborative to work as a facilitator within the CLAHRC team. This brought the benefits of someone with insider knowledge of the practice environment and the improvement process, as well as local political knowledge and longstanding local professional relationships. Due to financial constraints within the health care sector and the wider CLAHRC programme, the payments available to participating practices were reduced and the collaborative learning events were reduced from three events to two and from a full to half day. Additional opportunities for meeting and sharing experiences were, however, provided through five WebEx seminars scheduled at the outset of the project.
Selection was different in Phase 2 as 10 of the 11 practices were from the same geographical and administrative area of Greater Manchester (which had 5 practices involved in the first collaborative and from where the practice nurse facilitator was seconded). This was a deliberate strategy building on the local profile of the initiative and utilizing the seconded facilitator's pre-existing relationships to assist with engagement. The facilitators liaised with in-house information technology experts to install IMPAKT− and then worked with practices to interpret and use data from the tool, as part of the process of interrogating and verifying practice registers to identify patients with CKD. As in Phase 1, once patients with CKD were identified, the focus turned to achieving optimal patient management.
Implementation
The first step involved establishing an expert faculty to review the evidence on CKD and agree the scope and aims of the collaborative. The faculty included clinical staff from primary and secondary care, patient representatives and individuals with expertise in improvement. Two overarching objectives were established: to halve the gap between recorded and estimated prevalence and to ensure that 75% patients with recorded CKD had their BP managed according to the targets recommended in national guidelines (<140/90 for patients without proteinuria; <130/80 for patients with proteinuria). BP management was identified as the measure reflecting the overall quality of CKD care as it links to progression of CKD and cardiovascular outcomes.
Phase 1 Collaborative
Nineteen practices from four administrative areas within Greater Manchester took part in Phase 1. The project budget was sufficient to support involvement of 4–5 practices per area (representing 7–10% of the practice population). Practices were recruited by a mix of self-selection following advertisement of the initiative and nomination by local NHS managers. Recruited practices represented different sizes (as measured by patient 18+ list size, range 1671–9974) and adult CKD prevalence at baseline (range 1.5–5.9%). Once enrolled, practices were invited to the first of three joint learning events. Each practice was encouraged to send three staff members who would form the practice improvement team. To reflect the multi-disciplinary nature of the project, it was suggested that the improvement team should include General Practitioner, nursing and administrative representation. The first learning event introduced the improvement collaborative methodology, CKD guidelines and improvement targets for the collaborative. Subsequent learning events addressed issues such as building effective improvement teams, creating a receptive context for change and sustaining improvements in practice. Between the learning events, improvement teams were expected to test and apply planned changes using PDSA cycles. Two facilitators made regular practice visits to support the improvement process and provide help with activities such as data searches, managing practice registers, developing process maps and advising on how to overcome particular barriers or problems. This latter activity was informed by an initial assessment of the practice context to identify factors that could facilitate or impede improvement, for example, the way in which the practice was usually run, issues of leadership and culture, the level of teamwork and communication.
All practices were required to submit monthly data relating to the numbers of patients on the CKD register, numbers tested for proteinuria and the number of patients with BP managed to target. These data were analysed by the project team and reported back to practices on a monthly basis in the form of run charts, which presented progress against the key indicators over time both for their own practice and the collaborative as a whole. This allowed individual practices to benchmark progress against their peers; it also enabled the improvement facilitators to identify areas where more targeted input and support was required.
At project inception stakeholder input had indicated that uptake of the improvement programme would only be possible with staff time reimbursement. As part of the implementation strategy, therefore, practices received financial resources to secure protected time for improvement teams; different practices spent this in different ways including locum doctor cover to release physicians for improvement work and buying additional hours from practice staff. In addition in Phase 1, a small additional per patient payment was made for completing key stages of the improvement process (baseline data collection and attendance at the three learning sessions).
Moving from Phase 1 to Phase 2
At the end of Phase 1, a closing meeting was held to share the experiences and successes of the participating practices. The facilitation team also reflected on the learning gained during the collaborative, informed by the formative evaluation that had been ongoing throughout the implementation process (and which is detailed more fully in the following section). This led to the development of a CKD improvement guide, which summarized the key activities involved in implementation: creating a foundation for improvement, identifying patients with CKD, achieving optimal management of patients with CKD and ensuring improvements are sustained. This guide, complete with accompanying resources and links to other useful available information, was made available as an online resource. It also led to discussions with a CLAHRC initiative in another region of the country that had been involved in developing a data extraction and audit tool to analyse practice registers in relation to patients with CKD. The two CLAHRCs agreed to collaborate to develop a programme known as IMPAKT− (IMproving Patient care and Awareness of Kidney disease progression Together).
Phase 2 Collaborative
The IMPAKT™ tool formed a central part of the evidence and implementation resource for Phase 2 of the improvement collaborative. Other changes from Phase 1 included the appointment of a practice nurse from one of the practices that had been involved in the Phase 1 collaborative to work as a facilitator within the CLAHRC team. This brought the benefits of someone with insider knowledge of the practice environment and the improvement process, as well as local political knowledge and longstanding local professional relationships. Due to financial constraints within the health care sector and the wider CLAHRC programme, the payments available to participating practices were reduced and the collaborative learning events were reduced from three events to two and from a full to half day. Additional opportunities for meeting and sharing experiences were, however, provided through five WebEx seminars scheduled at the outset of the project.
Selection was different in Phase 2 as 10 of the 11 practices were from the same geographical and administrative area of Greater Manchester (which had 5 practices involved in the first collaborative and from where the practice nurse facilitator was seconded). This was a deliberate strategy building on the local profile of the initiative and utilizing the seconded facilitator's pre-existing relationships to assist with engagement. The facilitators liaised with in-house information technology experts to install IMPAKT− and then worked with practices to interpret and use data from the tool, as part of the process of interrogating and verifying practice registers to identify patients with CKD. As in Phase 1, once patients with CKD were identified, the focus turned to achieving optimal patient management.
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