1. Dialysis Clinic Process Improvement Analysis Adam Roy Dorothy Fisher Janelle Bryant Joel Mikuta Sherri Mesquita Michelle Himes

2. 2 Dialysis Overview  60% of Dialysis patients are ambulatory and are transported by way of ambulatory services  The majority of patients are Medicare vs. Medicaid  Each patient’s treatment at the clinic is about 3-4 hours, 2 to 3 days per week.

3. 3 Types of Treatment Areas  Hemodialysis -is the most common way to treat advanced kidney failure.  The blood is pumped out of your body to an artificial kidney  Requires patient to follow a strict treatment schedule, take medications and, usually, make changes in diet.

4. Treatment Area  Peritoneal Dialysis- Peritoneal dialysis (PD) has been a widely accepted method of treating end stage renal disease (ESRD) the most common method of home dialysis.end stage renal disease (ESRD) home dialysis  While many dialysis patients in the United States go to a dialysis center, PD offers more flexibility by allowing patients to dialyze at home, at work or on vacation.

5. Patient Treatment Needs  Patients have a team of Nurses, Dietician, and Social Worker  Fluid Restriction  Patients have a strict Kidney Diet

6. Current State Process

7. Common Process “Pain Points” Issue # 1  Incidence of bloodstream infections related to dialysis treatment  Bacterial infections are most common type  37,000 infections annually in the U.S.  $23,000 per related hospitalization Issue # 2  Extended patient wait times for treatment  Creates a domino effect for other patients  Increases clinic staff stress level  Leads to errors and often further delays

8. Process Improvement/Solutions Issue # 1  Incidence of bloodstream infections related to dialysis treatment Solution  Development /implementation of staff-level checklists at key points where infections can occur  CDC-recommended  Requires active management oversight and auditing to ensure staff compliance  Facilitate staff training around the need to follow proper protocols relative to venous site infection prevention

9. Issue # 2  Extended patient wait times for treatment Solution  Implement process workflow reengineering utilizing “lean” principles  Limit # of patients beginning treatment at any given time  # is dependent on clinic size  Critical to manage patient expectations  Routinely audit process for course corrections  Facilitate staff training around the need to stagger patient appointment times Process Improvement/Solutions (Cont’d)

10. Future State Process Process enhancement points

11. 11 Performance Metrics Issue # 1  Incidence of bloodstream infections related to dialysis treatment Measurement (A) : # of catheter-site infections vs. current baseline Frequency : Metric calculated and reported to the National Healthcare Safety Network (NHSN) and appropriate clinic staff members every 30 days Goal: Reduce infection rate by 50% within the initial 60 days Measurement (B): Auditing of recommended practices around central venous catheter care, minimum scrub and soaking time for antispetics and proper hand hygiene/gloving practices Frequency: Monthly observational audits and staff re-training on an as-needed basis Goal: Conduct at a minimum one formal audit each 30 days and informal audits on an on-going basis

12. Performance Metrics Issue # 2  Extended patient wait times for treatment Measurement (A) : Average patient wait time to begin treatment vs. current baseline Frequency : Metric calculated monthly and reported to appropriate staff members every 30 days Goal: Reduce average wait time by 30% within the initial 30 days and 50% within 60 days Measurement (B): Patient customer satisfaction levels (specific to treatment wait times), as reported by a random survey distributed each week Frequency: Metric calculated monthly and reported to appropriate staff members every 30 days Goal: Increase patient satisfaction rates around wait time by 50% in terms of favorable responses versus baseline Measurement (C): Staff satisfaction/stress levels, as reported by a self-reporting survey Frequency: Metric calculated monthly and reported to appropriate staff members every 30 days Goal: Increase overall staff job satisfaction level by 25% (30 days) and 50% (90 days) versus baseline

13. Conclusions  Dialysis clinics serve a critical need for a sensitive patient population  Key process improvements can be centered around:  Customer service (reduced wait times/delays)  Patient safety (reduced catheter site infections)  Staff job satisfaction (reduced self-reported stress levels)  Routine monitoring/reporting/training is critical to ensuring the above improvements remain impactful moving forward

14. Reference Material  http://www.nephrologynews.com/articles /109727-how-applying-lean-principles-in- dialysis-improved-efficiency-and-patient- satisfaction http://www.nephrologynews.com/articles /109727-how-applying-lean-principles-in- dialysis-improved-efficiency-and-patient- satisfaction

15. Questions?