Creating a model for improved chronic kidney disease care: designing parameters in quality, efficiency and accountability

BACKGROUND: Observational and randomized controlled studies suggest that patients with stage 4 and 5 chronic kidney disease (CKD) derive morbidity and mortality benefit from being followed up in multidisciplinary, allied health clinics. It remains unclear how these clinics should be structured in order to optimize an efficient use of resources. The objectives of this study are (i) to describe 'human' resource utilization in an established 'traditional' multidisciplinary CKD clinic and (ii) to optimize efficiency and accountability of this multidisciplinary CKD clinic while maintaining or improving delivered quality of care. METHODS: We conducted a prospective, cohort, intervention study in the multidisciplinary CKD clinics at a university-affiliated hospital in Winnipeg, Canada. There were 480 patients identified as requiring multidisciplinary care (68% male; 32% female; 64% Caucasian, 25% First Nations, 7% Asian; mean age 61), and the majority of these were in stages 4 and 5 CKD (80%). The aetiologies of CKD included diabetes (53%), hypertension (10%) and glomerulonephritis (GN) (19%). At baseline, process engineering analyses were conducted on resource use and workflows within the clinics. The intervention entailed clinic restructuring including changes to scheduling templates and documentation format as well as standardization of practitioner roles. Cross-sectional data to serve as surrogates for quality of care and efficiency were collected 1 year pre- and post-intervention. RESULTS: Optimization of clinic structure did not significantly change the cycle times among nurses, dieticians and pharmacists, but nephrologists' cycle time decreased from 13.8 min [interquartile range (IQR) 8-17] to 10.0 min (IQR 10-15) with P < 0.001. Patient throughput time decreased from 73 min (IQR 51-95) to 68.5 min (IQR 55-80). Compliance with established practice guidelines prior to clinic restructuring was 61% for BP (<130/80); 69% for haemoglobin (110-120 g/dL); 69% for ASA use; 63% for beta-blocker use; 43% for ACEi/ARB use; 64% for statin use, and did not change significantly post-intervention. CONCLUSIONS: Optimization of multidisciplinary CKD clinic structure using a standard process engineering methodology improves resource utilization while maintaining (without compromising) quality of care. The delivery of care is accomplished without the need for additional resources and with decreased reliance on physician input. The methodology proposes a useful algorithm for dynamic monitoring of quality metrics for clinical care linked directly to specific allied health inputs.