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Implementation of a Quality Management System (QMS; ISO 9001:2008;
ISO-EN 15224:2012) on Key Performance Indicators (KPIs) in a
Belgian Predialysis Clinic and Dialysis Unit
E.Gheuens1, W.Engelen1, K.De Boeck1, K.Bouman1,
1
2
3
1
J. Marynissen , B. de Kort , G. Kortz , R.Daelemans
London 2015
Table 1: Follow-up.
Pre-dialysis
clinic n=69
1ZNA
Kidney Clinic, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
2Kleemans Organisatieadvies, Breda, the Netherlands
3LRQA Lloyd’s Register Nederland BV, Rotterdam, the Netherlands
Introduction
Results
In 2008 a multidisciplinary pre-dialysis clinic, with a renal
nurse, a renal dietician, a dedicated social assistant and
a nephrologist, was started in the ZNA Kidney Clinic. In
2012 this pre-dialysis clinic and the dialysis unit became
ISO-certified (ISO 9001:2008),
offering a protocol driven
approach, evaluated in PDCAcycles (Figure 1). Since the
beginning of 2014 our Kidney
Clinic is ISO-EN 15224:2012
(Healthcare) certified.
Figure 1. PDCA-cycle
Patients from the multidisciplinary pre-dialysis clinic
needed significantly less urgent start of dialysis (Table
1). More frequently an AV fistula was present at start
(Figure 2). At the start of renal replacement therapy,
there was a trend to shorter hospitalization in this
population (Table 1). The advantage of the pre-dialysis
care became more apparent after one year of dialysis.
At that time there was a highly significant difference
in use of AV fistulas in favour of the patients followed
in the organized pre-dialysis care (Table 1). There was
a trend to lower mortality at one year of dialysis in the
latter group.
Methods
We examined the influence of organized, multidisciplinary care on the outcome at one year of dialysis, against
the group of patients on standard care or referred too
late. Of all patients, starting dialysis, patient characteristics were registered at start and after one year of renal
replacement therapy, as well as dialysis access.
We also did an observational analysis of some of the Key
Performance Indicators (KPI) in the balanced score card
of our dialysis units (dialysis adequacy, infection rates,
NPS, absence through illness).
The quality of life is continuously being assessed with
the SF-36 questionnaire. This questionnaire is taken
when a patient enters into the multidisciplinary pre-dialysis clinic and is repeated six weeks and one year after
the start of dialysis.
A survey of patient- and co-worker satisfaction in the
dialysis unit was performed (in 2011 before acquisition
of an ISO 9001:2008 certification and repeated in 2013)
based on standardized and validated questionnaires:
40 patients (48 % of our dialysis patients) and 55 coworkers (60 % of our co-workers) returned the questionnaires. After ISO acquisition, patient satisfaction
increased from 87% to 90% (haemodialysis remained
at 84%; peritoneal dialysis increased from 90% to 96%).
The high and increasing NPS is an indicator of the
loyalty that exists between our dialysis unit and the
patients.
Satisfaction of co-workers decreased from 77% to 68%,
due to “Too much ISO”:
• too much change in a short period;
• imperfect communication and feedback;
• increased work load.
In the beginning of 2015, after improvement of communication through workshops, the co-worker satisfaction increased to 76%.
46 % of the co-workers experienced their job as a ‘high
risk job’ and 21% as a ‘high strain job’, but systematic
appraisal of co-workers resulted in a relative decrease
of absence through illness (-36.52%).
Standard p-value of
care n=62 difference
Follow-up pre-dialysis
months of follow-up (mean-SD) 21.9 (19.8)
renal biopsy
26.1%
hepatitis B vaccination
18.2%
Start dialysis
start dialysis urgently
23.5%
PD at start dialysis
17.6%
AV fistula at start
38.2%
hospitalisation at start (mean days-SD) 13.4 (21.3)
1-year outcome
n=47
PD as dialysis modality
34.4%
AV fistula as vascular access
58.8%
hospitalisation during year 1 (mean days-SD) 33.0 (50.7)
transplantation
2.7%
mortality
30.6%
30.3 (30.1)
15.1%
21.4%
0.067
0.174
0.840
43.5%
32.3%
19.4%
17.3 (27.6)
n=34
21.6%
23.8%
30.5 (37.2)
8.1%
41.9%
0.015
0.053
0.018
0.349
0.134
0.002
0.790
0.164
0.171
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Predialysis
6weeksafterstartof
dialysis
12monthsafterstartof
dialysis
Figure 3: Total SF-36 (mean ± SD).
100%
95%
90%
85%
80%
75%
70%
65%
60%
aug/10
feb/11
sep/11
apr/12
okt/12
mei/13
nov/13
jun/14
dec/14
Figure 4: Proportion of patients with Kt/V > 1.2.
1. CQ-Index (Consumer Quality Index) for patients.
To calculate the Net Promotor Score (NPS) we used the
question: “Would you recommend our dialysis unit to
other dialysis patients?”
The quality of life of our patients is at its lowest at the
start of dialysis, but returns almost to the pre-dialysis
value after one year of dialysis (Figure 3).
2. JCQ (Job Content Questionnaire)
Over a period of almost 3 years we noticed an increase
in the proportion of patients with a Kt/V >1.2 with 11%
amounting to over 90% of our haemodialysis patients
achieving a Kt/V > 1.2. (Figure 4, Table 2).
KPI
2011
2014
Absolute
change
Patient satisfaction
87%
90%
3.00%
3.45%
47
51
4
8.51%
Rates of catheter sepsis have been historically below
the desired threshold of 1 per 1000 catheter days, and
continued to improve (Figure 5).
Co-worker satisfaction
77%
68%
-9.00%
-11.69%
Abscence through illness
5%
3%
-1.95%
-36.52%
Kt/V (% pat>1.2)
80%
91%
11.00%
13.75%
3. COPSOQ (Copenhagen Psychosocial Questionnaire)
for co-workers.
The survey of co-worker satisfaction was repeated in
2015.
Figure 2: HD Vascular access at start of dialysis
jul/15
Table 2: Changes in KPI
NPS
Rates of peritoneal dialysis peritonitis remain below
the desired threshold of
0.90
less than 0.67 per year
0.80
0.78
at risk (Figure 6). Lately
0.70
0.67
the rates have gone up
0.60
a little and at the mo0.56
0.52
0.51
0.50
ment possible causes
0.40
are being analysed and
0.34
0.30
an action plan is under
0.20
development (PDCAcycle), although the risk 0.10
0.00
is still well below the
2009
2010
2011
2012
2013
2014
threshold.
Figure 5: Rates of catheter sepsis/1000 catheter days.
Relative
change
0.50
0.46
0.45
0.40
0.40
0.39
0.35
0.30
0.30
0.27
0.25
0.20
0.20
0.15
0.10
0.05
0.00
2009
2010
2011
2012
2013
2014
Figure 6: Rates of PD-peritonitis/year at risk.
Conclusion
Implementation of a QMS, offering a protocol driven approach evaluated
in PDCA-cycles, in a predialysis kidney clinic and dialysis unit, resulted in
improvement of several KPIs (less urgent start of dialysis, presence of AV fistula,
haemodialysis adequacy, patient satisfaction and quality of life, NPS co-worker
satisfaction, absence through illness of co-workers and control of infection rates).
This requires a complex set of measures and involvement of a multidisciplinary
team, leading to fundamental changes in the culture of the unit and the teams.
Contact: ronald.daelemans@zna.be
Poster Design: Dirk De Weerdt
www.ddwdesign.be
Po674