Measuring the quality of health care delivery is a fundamental step towards healthcare improvement. The focus to date has been on common conditions such as diabetes; the number of measures that apply to urological conditions is therefore very limited. To address the need for determining the clinical outcomes of a specific chronic urologic condition, we have developed measures of care and outcomes for patients with posterior urethral valves (PUV). The purpose of this study is to optimize the documentation of these measures in order to track the efficacy of care, with the ultimate goal being improvement in the clinical outcomes and enhanced value for the patient.
A prospective IRB approved study was undertaken at our institution between 2011 and 2012. A panel comprised of quality improvement consultants, and faculty from the pediatric divisions of Urology and Nephrology identified candidate measures to use as metrics of clinical outcomes for patients with PUV; serum Creatinine (Cr), Cystatin C GFR (cGFR) and chronic kidney disease stage (CKD). Additionally we created an institutional ‘Best Practice' care plan for these patients, to reduce the variability of care between providers. Analysis of the processes involved in successful implementation of the care plan was performed (Fig 1). Interventions to improve documentation of the selected measures and care plan were undertaken. The interventions included education about the ‘Best Practice Plan', passive alerts in the electronic medical record (EPIC alerts), performance feedback, and increasing visibility of the measures within our system. Tests of change, Plan-Do-Study-Act (PDSA) ramps of the interventions were conducted on every PUV patient encounter during the study period, and successful interventions were adopted and made operational.
The baseline reporting levels of the selected measures for PUV outcomes included; Cr = 57%, cGFR = 31% and CKD =33.3%. At the completion of the interventions over a six month period, the rate of reporting of all selected measures had improved; Cr = 95.5% (Fig 2), cGFR = 73.9% and CKD = 60%. The interventions included pre & post-education test of knowledge which showed a statistically significant improvement for nurses and Nephrologists.
The Best Practice plan for patients with PUV was widely accepted by the Urology and Nephrology teams with an increased awareness of timing and appropriateness of diagnostic testing. The interventions with the highest reliability demonstrated early and sustained adoption by the staff i.e. EPIC alerts. These results showed an improved continuity of care for the patients, reduction in duplicated testing and an overall cost saving. Improvement science is a powerful tool that can be utilized to define quality care, decrease variability and increase value to both the patient and the healthcare system.