# How Can We Decrease Early Dialysis Initiation? An Interactive Quality Improvement Teaching Case for Health Care Providers and Narrative Review of Quality Improvement Methodology

## TL;DR

This paper presents a nephrology-focused educational case and review on using quality improvement methods to delay early dialysis initiation.

## Contribution

A novel interactive teaching case and narrative review on applying quality improvement methodology in nephrology care.

## Key findings

- A nephrology-oriented QI case demonstrates practical use of QI tools like PDSA cycles and run charts.
- Clear goals, stakeholder engagement, and evidence-based guidance are essential for successful QI initiatives.
- The framework can be applied across various clinical areas beyond nephrology.

## Abstract

Quality improvement (QI) initiatives use a team-based approach to problem-solving clinical and health system issues. All QI initiatives require the coordinated efforts of health care professionals and other stakeholders to encourage the provision of evidence-based clinical care. Most clinicians understand the principles of QI but may lack the training necessary to undertake individual projects.

An educational, nephrology-oriented clinical case was created based on the IDEAL study on timing of dialysis initiation, a prioritized quality indicator in several provinces. The case illustrates how to utilize commonly employed QI methodology and to provide a pragmatic framework for both developing and running a QI project. Core concepts addressed in this review include how to perform a QI chart audit, identification of a quality-of-care problem, engaging stakeholders, and how to conduct a root cause analysis that leads to selection of QI measures and change solutions. Last, plan-do-study-act (PDSA) cycles and interpretation of data using run charts are highlighted.

PubMed and Google scholar were used as sources of published QI methodology.

This nephrology-oriented QI case highlights how a core set of QI principles and tools can be used to improve clinical care. This review demonstrates that determining clear goals, utilizing evidence-based guidance to improve timing of dialysis initiation, engaging the appropriate stakeholders, identifying a feasible and measurable change, and tracking if that change leads to improvement are essential components of all QI initiatives. The above framework can be utilized in a variety of clinical areas both within and beyond nephrology-specific care.

Considerations regarding QI-specific data analysis were not addressed as they were beyond the scope of this review.