The KDQOL-36: A Team Tool for Plan of Care & Facility-Level Quality Improvement (QAPI)

In early May 2014, the Ontario (Canada) Renal Network contacted Medical Education Institute, Inc. asking how dialysis facilities in the U.S. use the KDQOL-36 survey and how facility outcomes have changed related to its use. I posed that question to the Council of Nephrology Social Workers' listserv. A social work colleague gave me permission to share her comments.

"The KDQOL-36 facilitates targeting/focusing discussions patients and I have on relevant elements of their clinical care as well as psychosocial well being. The survey has allowed me to explore these issues and then identify other issues associated with the clinical outcomes and complaints the patients reported. This allowed me to alert the rest of the renal team to issues they needed to explore further and address in the plan of care. It also allowed other staff members to add the KDQOL-36 findings to their assessments. I use the information from the KDQOL-36 as a baseline for further information gathering. My job is to assess and maximize the patient's psychosocial well being through the assessment process and to plan interventions based on that assessment. The KDQOL-36 is an important tool in that whole process."

She went on to say, "I use individual patient data I collect from the KDQOL-36 and when I get similar responses from different patients, I use the systemic issues for QAPI projects. For example, I used data from KDQOL-36 feedback to conduct facility-level (QAPI) projects in the areas of transplant and vocational rehabilitation where there seemed to be two common misconceptions—starting dialysis automatically places you on the waiting list for kidney transplant and dialysis patients can't work. I was not happy with this feedback and decided to do projects on both to educate and offer options in these two areas. I provided individual transplant and vocational rehabilitation education, discussed options, provided written resource information, explained the referral process, and had patients sign forms listing what they had received and their goals/wishes. From these two projects I learned almost 28% of our facility's patients were awaiting kidney transplants and those not on the waiting list had valid reasons unrelated to lack of education. I learned that we average 5 to 8 transplants yearly. I also learned that nearly 50% of patients in the working age group (18-54) were working full- or part-time, much higher than the 20% reported in the ESRD Networks Annual Report¹. This gave me the opportunity to discuss with unemployed patients why they weren't working and identify other ways to engage in life and stay active. I was able to identify these two areas of concern by using the KDQOL-36."

Having heard from some social workers that they have problems getting the KDQOL-36 surveys from home patients, I asked my colleague her experience. She told me, "My PD patients are actually easier to get KDQOL-36 surveys from. We have a high completion rate and high rate of participation in the plans of care because of my delivery. I show enthusiasm and excitement and present these as fun, informative projects that the patients and I can do together. I see social workers are professional motivators and facilitators for positive change in people. I use that "gift" to help patients overcome behaviors/actions (e.g., no fistula, diet and fluid intake, personal hygiene, etc.) that staff may identify as "noncompliant" and potentially harmful. My patients are receptive to all these "regulatory tasks" that we can engage in together. Who doesn't love to talk about themselves? Not many. I'm open to any tool that makes me better at what I do for a living and allows me to better "reach" my patients. Too many may be looking at the KDQOL-36 as a regulatory mandate vs. a useful tool."

She went on to tell me about her experience during a recent state survey. "We just had our survey and got no deficiencies. The surveyor interviewed me and asked the level of KDQOL-36 participation (96%) and care plan participation rate (100%). These were new interview areas. The surveyor also asked about QAPI and the new CMS focus on collaborative treatment. I felt right at home with the interview questions. I've been through 10 surveys in my 17 years as a renal social worker, but for the first time, I felt vindicated. For years I have felt like an alien as my coworkers considered their only role was to do dialysis for patients. Now they know it's all about teamwork with patients."

"I think we need to gear every patient contact toward soliciting and enrolling our patients in a partnership or they will consciously or unconsciously resist in different ways. It's basic Human Relations 101. Anyone who knows me knows I will do almost anything if you ask me...but I won't be so accommodating if you demand it of me or do it to me. We can see the Networks' patient engagement effort as extra work...or what we should have been doing all along. Ultimately it is up to each social worker to be open to always improve how we provide care including partnering with the patient and not merely doing for patients. Dialysis needs to be a collaborative team process. The KDQOL-36 is helpful in pursuing that goal/mission."

How my colleague uses the KDQOL-36 reminded me of the National Patient Safety Foundation's report,² which includes a frequently quoted phrase—"Nothing about me, without me". In my opinion, patient-staff communication, the comfort and safety of the facility for both patients and staff, and ultimately the outcomes of dialysis care would improve measurably if those of us working in dialysis chose to adopt "Nothing about me, without me" as our mantra.

References

1. Centers for Medicare & Medicaid Services, 2011 Summary Annual Report, http://www.esrdncc.org/index/cms-filesystem-action/resources/SAR2011_website_posting.pdf (accessed May 12, 2014)
2. The National Patient Safety Foundation, National Agenda for Action: Patients and Families in Patient Safety Nothing About Me, Without Me, 2003, http://www.npsf.org/wp-content/uploads/2011/10/Nothing_About_Me.pdf (accessed May 12, 2014).