September News

LKN Health Equity e-module available now!

“My interest in quality improvement began on 19th of March 2015 following the death of a patient under my care from a hyperkalaemic cardiac arrest. One might say that an unexpected death due to hyperkalaemia is a never event on a renal ward. In seeking to understand what went wrong, I learnt first about human factors, and this led me to quality improvement (QI). 

If we consider what high-quality healthcare should look like, first and foremost it should be: 

• Safe 

• Diagnostics and treatments should be Timely and not delayed

• The treatments we give should be Effective and evidence-based 

• Our processes should be Efficient 

• Outcomes and access to care should be Equitable

• Care should be Patient/ Person-centred

This summer, with Canada and Greece ablaze, we might also add ’sustainable’ as an additional dimension of quality, both from an environmental and financial sustainability viewpoint. These domains of quality can be remembered as the mnemonic – STEEEP. 

Most of us will be familiar with the principles of clinical audit, but this is a tool primarily to provide quality assurance (QA). What do we do when we identify an area of the care we deliver that requires improvement? The audit cycle is too slow and cumbersome to deliver rapid improvements in care. This is where QI methodology comes in. 

If I asked you how you would assess the effectiveness of a new treatment for a condition, I dare say that you would immediately suggest a ‘randomised, double blinded, placebo-controlled trial’. However, if I asked you how you will go about demonstrating that one process or pathway achieves better results than another you might struggle. You might suggest doing an RCT again. However, this would be cumbersome and would likely to take a long time before you had your answer. 

Quality improvement (QI) has its roots in industrial process design where profit is king and having more efficient, and by extension cheaper processes, can give you a competitive advantage in the marketplace. QI describes a systematic approach to improvement, but unlike research methodology, the aim is not to remove confounders and eliminate bias but simply identify what works to achieve an improvement. This is not to say that QI lacks statistical robustness in defining when there has been an improvement. 

What do you want to improve?

There are a number of core principles in QI. The first step is to define your goal:

1. What do you want to improve?
2. How much do you want to improve it by and,
3. By when?

What do you want to change?

“Every system is perfectly designed to get the results it gets”

The next step is to diagnose. What in the system or process you are interested in that might be changed? We need to identify the drivers for the outcome we wish to improve.  To this end, there are some key tools

1. the driver diagram 
2. root cause analysis 
3. the Pareto chart 
4. the cause-and-effect diagram (AKA Fishbone or Ishikawa diagram) 
5. Scatter plots

How do you know you’ve improved?

“What you don’t measure you don’t know. What you don’t know you can’t improve” 

Regular measurement of both outcome and process measures, is the absolute key element for quality improvement – to paraphrase Tom Cruise in the film Gerry McGuire “Show me the improvement!”

Our key tool here is the statistical process control, or SPC, chart. The SPC chart helps us understand when the change we have made to the system or process has resulted in an improvement and provides the statistical robustness. All systems experience natural variation; we are interested in identifying what is known as special cause variation which may be for the better or worse.

Tests of change 

So next, we are going to make changes to our system or process and test if those changes improve the measure we are interested in. This is where the plan-do-study-act, better known as PDSA, cycle comes in.

PDSA cycles are simply a means of testing whether a change makes a difference, does that change result in special cause variation? If it does and the change leads to an improvement, we adopt that change permanently and scale up. Changes can be introduced sequentially or multiple interventions/ changes can be made simultaneously. 

QI is not rocket science. It is just the application of simple but rigorous methodology and something I think as healthcare professional used to practising evidenced based care, that we should be able to adopt into our practice.” 

If you have a QI idea, or having started a QI project and need some help and guidance, Conor will be  holding regular QI surgeries on Teams soon.

If you’d like to speak to Conor, please email us on:  [email protected] to book a slot.

You will be able to find more on QI on the LKN website soon. 

Improving Access to Living Kidney Donation for Black Kidney Patients

This Quality Improvement project (QIP) is a collaboration between Gift of Living Donation (GOLD), Imperial College Healthcare NHS Trust, Guy’s and St Thomas’ NHS Foundation Trust, and King’s College Hospital NHS Foundation Trust, with support from the London Kidney Network (LKN).

We know that Black patients are less likely to have a pre-emptive transplant that their white peers, and at the heart of this project is the desire to reduce health inequality. The ultimate aim of this project is to increase pre-emptive transplantation for Black African Caribbean kidney patients. The immediate aim is to help facilitate more conversations about living donation between patients and their families which will facilitate more presenting donors, thus improving their access to living kidney donation.

Unfortunately, many Black patients opt for dialysis first and transplantation second due to a lack of understanding and knowledge about living donation. GOLD wants to change that perception. Living donor kidney transplantation offers suitable patients the best chance to avoid commencing dialysis.

GOLD developed the Phone Buddy Scheme to provide Black patients with information and education on living donation from a community and cultural perspective. This collaborative QI project provides clinicians with the ability to better engage with Black patients when discussing living donation by recognising some of the cultural context around discussing kidney disease with family and friends.

Since its launch in February there have been over 60 patient referrals, 5 presenting donors and plenty of positive patient feedback demonstrating that referrals to the Gold Phone Buddy Scheme and the opportunity for Black patients to talk with someone from their community has been life changing and empowering:

“The process has started and it’s all thanks to GOLD. I never would have thought that I could talk to my family about living donation and I’m so glad that I did as my sister has offered to be a donor. I am so happy I was referred to the scheme as it has given me and my family hope.”

“I would like to thank you for setting me up with the GOLD Charity, this is so helpful even though you’re the professionals these people have been through it and so great to be able to talk to them a share their experiences so thanks again.”

Kidney Beam is now clinically proven to improve the health-related quality of life of kidney disease patients through ground-breaking research trial.

Dr. Sharlene Greenwood, Kidney Beam’s Clinical Lead and Consultant Physiotherapist at King’s College Hosptial, presented the initial results from The Kidney Beam Trial (ClinicalTrials.gov Identifier: NCT04872933) at UK Kidney Week earlier this summer. A multi-centre randomised controlled waitlist trial, supported by Kidney Research UK, aimed to evaluate the clinical value and cost-effectiveness of physical activity and wellbeing interventions delivered on the Kidney Beam digital platform.

“Previous clinical trials in this area have failed to show physical activity interventions resulting in an improvement to health-related quality of life, so The Kidney Beam Trial wanted to look at physical activity intervention using a digital platform, focusing on not only clinical value and cost-effectiveness, but also other outcomes such as health-related quality of life, physical function, patient activation, fatigue, anxiety, and depression. After all, symptoms such as fatigue and mental health have been highlighted by people living with kidney disease as being more important to them than clinical outcomes such as mortality.”, says Sharlene. 

28% of adults in the general population are insufficiently active, and people living with kidney disease are at particular risk from physical inactivity as this can lead to accelerated disease progression and a poorer health-related quality of life.

In 2020 Sharlene and the team at King’s College Hospital turned to existing digital health platform, Beam, to develop their online exercise solution specifically for kidney patients. The result of this collaboration was Kidney Beam. Kidney Beam offers access to progressive programs, live and on-demand classes, community and motivational support.  

The Kidney Beam Trial recruited and randomised 340 participants, assigning them to either the Kidney Beam intervention or to a waitlist control group. Kidney Beam participants were encouraged to attend twice weekly sessions of live or on-demand kidney rehabilitation over the 12-week intervention, and were also offered disease specific education sessions and support from a physiotherapy assistant who was trained in motivational interviewing.

After 12 weeks, researchers compared changes in health related quality of life and physical function between the two groups. Sharlene and her team found that patients in the Kidney Beam group showed significant and clinically important improvements in health related quality of life. 

The Kidney Beam intervention specifically was effective for the primary outcome of mental health-related quality of life, as well as the secondary outcomes of physical function, symptom burden, social interaction, anxiety and depression and patient activation. The results will facilitate the implementation of current guidelines on physical activity and inform future clinical practice.

The validation of Kidney Beam is of huge importance for people with kidney disease because despite the clinical significance of physical activity programs on health outcomes, very few local services offer this support in-person and now there is a trusted online alternative. 

These positive results show that Kidney Beam is:

• a lifestyle intervention that can improve the management of people living with kidney disease
• a viable and scalable model to be adapted for use globally and by other chronic conditions that are associated with sedentary behaviour and poor physical and mental health. 

“My very first session with Beam, I found it very helpful, and at the right pace for my stage 5“

“I love the pace of this video, its very well done. The consideration for those with a fistula is good too“

“Simple and easy stretches for armchair fanatics”

“I love the fact that there are a range of classes and for different levels and abilities. If you can’t make the live class you can follow it on demand, so it’s easy to fit into your everyday life. And the best bit is it’s free – no guilt about paying a subscription that you don’t use as much as you should!”

Kidney Beam is available free to every London kidney patient. Each Kidney Unit has a Beam Champion on hand to help you with posters, flyers, and information about how to use Kidney Beam. If you aren’t sure who your Beam Champion is, please email [email protected] to find out.

Supportive Care for Primary Care Webinar

The LKN Supportive Care Workstream will be running a webinar on Friday 29 September 2023 1300-1400.  It aims to help those working in Primary Care better understand Renal Supportive Care, and how they can help patients to live well with late-stage renal disease.