Using a Measuring and Monitoring Safety Framework to Improve Patient Care with Peritoneal Dialysis and Peritoneal Dialysis Catheter Dysfunction Rate: A Call to Action

The Saskatchewan Health Authority (SHA) - Kidney Health (KH) Program vision is to enhance the health, safety and quality of life of patients through a home first model of care, promoting peritoneal dialysis (PD) to better meet the health needs of patients in a collaborative manner, and to expand community partnerships. A current priority from the Saskatchewan Ministry of Health is to optimize care for persons within the community rather than in an institution or inpatient setting. Historically, the utilization of PD in First Nations and Métis people is low. A holistic participatory evaluation framework honouring protocol, traditions, culture, and spirituality was used to better understand the lived interactions of patients and families with kidney disease. The Truth and Reconciliation Calls to Action guided this work, in tandem with advice and wisdom of Indigenous Elders. Kidney Health partnered with First Nations and Métis Health Services SHA to develop strategies to promote home based therapies in a culturally sensitive manner, develop new models of care for rural/remote communities, and address four ‘Calls to Action” items 19, 20, 22(iii), and 23. Nîsohkamâtowak (a Cree word meaning ‘helping each other’) sharing events were hosted in local communities from 2015-2017 to better understand the lived experience of First Nations and Métis patients and families. Sharing circles embraced conversational methods/storytelling to gather knowledge and wisdom regarding patient and family experiences living with kidney disease. Videos/short stories have been gathered to promote a better understanding of cultural competency, blending traditional and western medicine, and to improve the care experience for patients and families in their home communities. A participatory evaluation framework was used to identify themes, and action items were shared with the patients and families, and community partners (transcription of videos, flip charts, and focus group findings, analysis to identify common themes, mapping to Calls to Action). As part of the Nîsohkamâtowak process, patients and family members were asked to provide guidance on priorities for action. The following priorities were highlighted: letting patients be in charge, more timely education, support in home communities, open communication, understanding and acceptance of kidney disease, more work with the youth, and cultural competency training for staff and physicians. The concept of patient safety in the home and community was explored which led to an opportunity to participate in national collaborative on Measuring and Monitoring Safety Framework (MMSF) with the Canadian Patient Safety Institute/Healthcare Excellence Canada. A unique aspect of collaborative included the potential to expand MMSF in terms of cultural lens through our partnership with First Nations and Métis patients and families. The MMSF was an 18 month learning program (2018-2019 in person workshops and KH program application of safety principles). The measurement and monitoring of safety in healthcare is an ongoing challenge and safety is not solely about measuring harm. The MMSF consists of five dimensions and associated questions that can be used to help understand the safety of care and service at multiple levels. The five dimensions are past harm, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning. Through the MMSF national collaborative, the KH clinical improvement team (CIT) addressed a number of quality and safety barriers that prevent patients from successfully performing home PD and assisted patients to remain on PD when their functional status changed. Program enhancements are needed to better understand and serve these patients in their home communities. Nationally, the target for primary PD catheter dysfunction (inability of the PD catheter to support adequate inflow and/or outflow, patient not able to train) for PD catheter insertions is set at <10% at 3 months. PD catheter dysfunction rates are associated with significant burden and hardship to the patient, and an overall increase in cost to the health system due to additional procedures/tests to diagnose and correct complications. Participation in the MMSF stimulated the development of the KH PD catheter outcomes database, and data collection was retrospectively set to 2016 to evaluate surgical and interventional radiology laparoscopic PD insertion techniques. Previous methods of PD catheter insertion resulted in high dysfunction rates at 3 months post procedure: PD catheter dysfunction rates (primary and secondary failure combined, secondary failure defined as patient able to train, but stopped due to PD catheter malfunction or flow, or non-catheter issues) were: 2016 25/62 (40.3%); 2017 19/71 (26.8%); 2018 11/50 (22.0%); 2019 12/54 (22.2%); and in 2020 5/57 (8.8%). Although PD dysfunction rates are improving, more work is needed to close this gap. Participation in the MMSF enabled the ability for the CIT to translate real time data so that it is useful to take action, stimulate gap analysis for process improvement, identify strengths and weaknesses, and promote a culture of safety and continuous improvement. The success of the MMSF and the CIT team to imbed quality and safety into daily practice showed a positive shift in safety culture and mapping the patient and family experiences enabled opportunities to include the Calls to Action into Kidney Health programs and services. The Measuring and Monitoring of Safety Framework (MMSF) collaborative provided a unique mechanism to focus quality and safety efforts within Kidney Health in Saskatoon, and through organizational partnerships at the provincial level to spread these concepts.

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