1. Decreasing Dialysis Patient-Provider Conflict (DPC) Session #5 – Step III Quality Improvement A Collaborative Presentation by Western Pacific Renal Network, LLC ESRD Network #17 Connie Lorenz, LMSW Patient Services Director 505 San Marin Dr., Bldg. A 300 Novato, CA 94945 Southern California Renal Disease Council, Inc. ESRD Network #18 Cecilia Torres-Correa, RN/BSN Patient Services Director 6255 Sunset Blvd., Ste. 2211 Los Angeles, CA 90028

2. What is Quality Improvement? (QI) “Quality Improvement is a method of planning and implementing continuous improvements in systems or processes in order to provide quality health care reflected by improved patient outcomes.”

3. ACTPLAN DO STUDY Networks #17 & #18 base their improvement process on the Model for Improvement developed by Associates in Process Improvement and utilized by the Institute for Healthcare Improvement (IHI). This model has two parts: Establishing what is to be studied and how to measure the improvements Using the PDSA rapid cycle to test changes QI Process - Example

5. Why Is QI So Important? Improvement comes from building and applying knowledge Significant, long-term, positive impact occurs after a thoughtful, studied approach QI tasks someone with responsibility

6. Purpose of DPC/QI QI tools were developed to assist facilities: To track the number, causes, and severity of patient-provider conflicts that occur in your facility To use the terms and definitions contained in the DPC Taxonomy & Glossary

7. Using Quality Improvement to Decrease Patient-Provider Conflict Allows for data collection related to conflict Provides trending analysis of conflict Creates objectivity toward conflict Identifies areas for improvement or training

8. QI Tracking Tools Graphs in Word and Excel Number of conflicts by month Types of conflicts by month Causes of conflicts by month

9. Starting Your Documentation DPC Tracking Tool provided: Used to describe conflict Used to describe intervention and resolution Is the patient/staff satisfied with the outcome of the conflict? Could the conflict have been handled more effectively? If yes, how?

10. Decreasing Dialysis Patient-Provider Conflict Tracking Tool Documentation Form (pg. 88) Date Conflict Occurred:Time of Day Conflict Occurred: Name(s) of Patients Involved in Conflict: Name(s) of Staff Involved in Conflict: Type of Conflict*: Cause of Conflict*: Description of Conflict: Intervention/Resolution of Conflict: Is patient satisfied with the outcome? Is the staff satisfied with the outcome? Could the conflict have been handle more effectively and why?

11. DPC/ Quality Improvement Taxonomy and Glossary Taxonomy - Three “At-Risk” Categories: Risk to self Risk to facility Risk to others Glossary - Dictionary, terms & definitions Define and understand the types To collect and analyze Promote common language Use in Quality Improvement

12. Types of Conflict* Non-adherence Noncompliance with or nonconforming to medical advice, facility policies and procedures, professional standards of practice, laws and/or socially accepted behavior toward others (Golden Rule) Verbal/Written Abuse Any words (written or spoken) with an intent to demean, insult, belittle, or degrade staff, patients, families, or others Verbal/Written Threat Any words (spoken or written) expressing an intent to harm, abuse, or commit violence towards staff, patients, families, or others Physical Threat Gestures or actions expressing intent to harm, abuse, or commit violence towards staff, patients, families, or others Physical Harm Any bodily harm or injury, or attack upon staff, patients, families, or others Property Damage/Theft Theft or damage to property on premises of ESRD facility Lack of Payment Refusal to maintain or apply for coverage or misrepresentation of coverage

13. Causes Of Conflict* Physical Environmente.g. Unit cleanliness, temperature, noise level, TVs Treatment Relatede.g. Infiltration, medication error, machine alarms Staffinge.g. Number and composition of staff, assignments Staff Professionalism/Training e.g. Staff talking about personal issues, competence Financiale.g. Nonpayment of fees, patient or staff seeking financial assistance from one another Non-adherencee.g. Missed, shortened treatments or breaking facility policy Scheduling/Transportatione.g. Wait time, on time, transportation Disruptive Behaviore.g. Yelling, swearing, inappropriate remarks, tampering with the machine or other unit equipment Other

14. DPC Conflict Log Date Conflict Occurred Time of Day Conflict Occurred Name(s) of Patient Involved in Conflict Name(s) of Staff Involved in Conflict Cause of Conflict Type of Conflict

15. Decreasing Dialysis Patient-Provider Conflict Tracking Tool JanFebMarAprMayJuneJulyAugSeptOctNovDecTotal Physical Environment Treatment Related Staffing Staff Professionalism/ Training Financial Non-adherence Scheduling/Transport Disruptive Behavior Other Total Table #1: Causes of Dialysis Patient-Provider Conflict by Month At the end of each month, indicate the number of conflicts that occurred during the month by cause. Look at patterns to assess trends. Facility Name: Year:

16. Decreasing Dialysis Patient-Provider Conflict Tracking Tool Graphs Graph #2: Number of Dialysis Patient-Provider Conflicts By Month At the end of each month, draw a circle for the month that corresponds with the number of dialysis patient-provider conflicts that occurred during the month. Connect the circles with a line to assess trends. Year: Facility Name:

17. Decreasing Dialysis Patient-Provider Conflict A QI Approach: Examples 1.Has the number of conflicts increased or decreased since the last review or in the past quarter? ● In the May QI meeting it was noted on the Number of Conflicts Graph that the number of conflicts had increased for both April & May. ● The QI Committee reviewed the Level of Conflicts Graph for those months and found that the reported conflicts were mainly Level 1 & 2. 2. Is there any pattern in the conflicts? The QI Committee looked to find commonalities by reviewing the Conflict Log and Causes of Conflict Graph. They found that: ●The same patient, who was an old patient who had returned from a lengthy hospitalization with a new AVF, had experienced several infiltrations when being put on by a fairly new staff member. ●The patient’s daughter, who was not usually in town, became very upset when this occurred and complained to the staff member who became quite defensive. The regular charge nurse was on maternity leave and different nurses were covering the shift. Over a period of weeks, the conflict had escalated into shouting between the staff member and the daughter and the daughter had refused to let the staff member assigned put her father on.

18. Decreasing Dialysis Patient-Provider Conflict (cont.) A QI Approach: Examples 3.Discuss and choose interventions that will address any patterns. ●The QI committee directed that more experienced staff stick new AVF’s. The DON was assigned to implement this change. ●The staff member was recommended for training in conflict management using the interactive training module in the DPC Toolbox and to be assigned to a mentor and have his cannulation skills assessed. The DON was assigned responsibility for the training and the charge for the mentoring and cannulation assessment. ●A family conference was advised where the family would be informed of the actions and the daughter would be asked to voice any complaints to the charge nurse away from the treatment area. The SW was assigned the responsibility of setting up the conference. 4.Upon review for improvements the next month, the number of conflicts had been successfully decreased.

19. Quality Improvement Training Preparation & Materials Needed Enter information on Conflict Logs Clarify details with staff, if needed Confer with others regarding types and causes of conflict, if needed Plot Data Graphs Schedule QI Committee meeting Prepare meeting room

20. Quality Improvement Training Conduct First Leadership Meeting Review DPC data Discuss: 1. Any trends observed 2. New interventions needed 3. Staff training needs A. Veteran staff- Follow up for understanding B. New staff - Initial orientation C. Retraining of staff for problem behaviors and attitudes 4. Individual patient issues to be addressed during patient care conferences

21. Quality Improvement Training Time Required: Variable: 1-3 hours Monthly or quarterly (minimum) data activities Preparation /Material Needed: Data preparation activities Collect Tracking Tool documentation forms

22. DPC Series Wrap-up Six Steps to Resolving Conflict 1. Share your feelings 2. Define the problem 3. Explore options. Look for possible solutions to the problems of both parties 4. Select and negotiate one option to work on 5. Take action 6. Get feedback

23. DPC Series Wrap-up Important Tips for Defusing Anger 1. Breathe Deeply 2. Remove Yourself 3. Reframe the Situation 4. Ignore Personal Attacks 5. Exercise Regularly 6. Violence is Unacceptable

24. Quality Improvement In Conclusion “….embrace the voice of CMS and the ESRD community in their directive to ensure that patients and providers in dialysis units are able to resolve the issues of conflict and improve the quality of care for all patients…..”

25. Thank you from Cecilia & Connie

26. Additional Resources *DPC Tip Sheet #2 - Staff Training Modules *DPC Tip Sheet #1 - Administration www.esrdnet17.org www.esrdnet15.org * Developed by ESRD NW#15

27. CEU Requirements EVALUATION! Evaluation forms can be found on NW #17 or NW #18 websites under: “CEU Evaluation for DPC WebEx Session 5” www.esrdnet17.org www.esrdnetwork18.org You must attend all 5 sessions to receive CEU credit! Please return completed evaluation forms by fax to: Social Workers - NW #17 (415) 897-2422 RNs - NW #18 (323) 962-2891