Decreasing Dialysis Patient-Provider Conflict (DPC)

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Decreasing DialysisPatient-Provider Conflict
(DPC)

• Session 5 Step III
• Quality Improvement

A Collaborative Presentation by
Western Pacific Renal Network, LLC ESRD Network
17 Connie Lorenz, LMSW Patient Services
Director 505 San Marin Dr., Bldg. A 300 Novato,
CA 94945
Southern California Renal Disease Council, Inc.
ESRD Network 18 Cecilia Torres-Correa,
RN/BSN Patient Services Director 6255 Sunset
Blvd., Ste. 2211 Los Angeles, CA 90028
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What is Quality Improvement? (QI)

• Quality Improvement is a method of planning and
  implementing continuous improvements in systems
  or processes in order to provide quality health
  care reflected by improved patient outcomes.

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QI Process - Example

• Networks 17 18 base their improvement process
  on the Model for Improvement developed by
  Associates in Process Improvement and utilized by
  the Institute for Healthcare Improvement (IHI).
  This model has two parts
• Establishing what is to be studied and how to
  measure the improvements
• Using the PDSA rapid cycle to test changes

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Why Is QI So Important?

• Improvement comes from building and applying
  knowledge
• Significant, long-term, positive impact occurs
  after a thoughtful, studied approach
• QI tasks someone with responsibility

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Purpose of DPC/QI

• QI tools were developed to assist facilities
• To track the number, causes, and severity of
  patient-provider conflicts that occur in your
  facility
• To use the terms and definitions contained in the
  DPC Taxonomy Glossary

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Using Quality Improvement to Decrease
Patient-Provider Conflict

• Allows for data collection related to conflict
• Provides trending analysis of conflict
• Creates objectivity toward conflict
• Identifies areas for improvement or
• training

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QI Tracking Tools

• Graphs in Word and Excel
• Number of conflicts by month
• Types of conflicts by month
• Causes of conflicts by month

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Starting Your Documentation

• DPC Tracking Tool provided
• Used to describe conflict
• Used to describe intervention and resolution
• Is the patient/staff satisfied with the outcome
  of the conflict?
• Could the conflict have been handled more
  effectively?
• If yes, how?

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Decreasing Dialysis Patient-Provider Conflict Tracking Tool Documentation Form (pg. 88)
Date Conflict Occurred Time of Day Conflict Occurred
Name(s) of Patients Involved in Conflict
Name(s) of Staff Involved in Conflict
Type of Conflict
Cause of Conflict
Description of Conflict
Intervention/Resolution of Conflict
Is patient satisfied with the outcome?
Is the staff satisfied with the outcome?
Could the conflict have been handle more effectively and why?
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DPC/ Quality Improvement

• Taxonomy and Glossary
• Taxonomy - Three At-Risk Categories
• Risk to self
• Risk to facility
• Risk to others
• Glossary - Dictionary, terms definitions
• Define and understand the types
• To collect and analyze
• Promote common language
• Use in Quality Improvement

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Types of Conflict Types of Conflict
Non-adherence Noncompliance with or nonconforming to medical advice, facility policies and procedures, professional standards of practice, laws and/or socially accepted behavior toward others  (Golden Rule)
Verbal/Written Abuse Any words (written or spoken) with an intent to demean, insult, belittle, or degrade staff, patients, families, or others
Verbal/Written Threat Any words (spoken or written) expressing an intent to harm, abuse, or commit violence towards staff, patients, families, or others
Physical Threat Gestures or actions expressing intent to harm, abuse, or commit violence towards staff, patients, families, or others
Physical Harm Any bodily harm or injury, or attack upon staff, patients, families, or others
Property Damage/Theft Theft or damage to property on premises of ESRD facility
Lack of Payment Refusal to maintain or apply for coverage or misrepresentation of coverage
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Causes Of Conflict
Physical Environment e.g. Unit cleanliness, temperature, noise level, TVs
Treatment Related e.g. Infiltration, medication error, machine alarms
Staffing e.g. Number and composition of staff, assignments
Staff Professionalism/Training e.g. Staff talking about personal issues, competence
Financial e.g. Nonpayment of fees, patient or staff seeking financial assistance from one another
Non-adherence e.g. Missed, shortened treatments or breaking facility policy
Scheduling/Transportation e.g. Wait time, on time, transportation
Disruptive Behavior e.g. Yelling, swearing, inappropriate remarks, tampering with the machine or other unit equipment
Other
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DPC Conflict Log
Date Conflict Occurred Time of Day Conflict Occurred Name(s) of Patient Involved in Conflict Name(s) of Staff Involved in Conflict Cause of Conflict Type of Conflict







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Decreasing Dialysis Patient-ProviderConflict
Tracking Tool
Table 1 Causes of Dialysis Patient-Provider
Conflict by Month At the end of each month,
indicate the number of conflicts that occurred
during the month by cause. Look at patterns to
assess trends. Facility Name Year
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Total
Physical Environment
Treatment Related
Staffing
Staff Professionalism/ Training
Financial
Non-adherence
Scheduling/Transport
Disruptive Behavior
Other

Total
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Decreasing Dialysis Patient-Provider Conflict
Tracking Tool Graphs Graph 2 Number of
Dialysis Patient-Provider Conflicts By Month At
the end of each month, draw a circle for the
month that corresponds with the number of
dialysis patient-provider conflicts that
occurred during the month. Connect the circles
with a line to assess trends.
Year
Facility Name
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• Decreasing Dialysis Patient-Provider Conflict
• A QI Approach Examples
• 1. Has the number of conflicts increased or
  decreased since the last review or in the past
  quarter?
• In the May QI meeting it was noted on the Number
  of Conflicts Graph that the number of conflicts
  had increased for both April May.
• The QI Committee reviewed the Level of Conflicts
  Graph for those months and found that the
  reported conflicts were mainly Level 1 2.
• 2. Is there any pattern in the conflicts?
• The QI Committee looked to find commonalities by
  reviewing the Conflict Log and Causes of Conflict
  Graph. They found that
• The same patient, who was an old patient who had
  returned from a lengthy hospitalization with a
  new AVF, had experienced several infiltrations
  when being put on by a fairly new staff member.
• The patients daughter, who was not usually in
  town, became very upset when this occurred and
  complained to the staff member who became quite
  defensive. The regular charge nurse was on
  maternity leave and different nurses were
  covering the shift. Over a period of weeks, the
  conflict had escalated into shouting between the
  staff member and the daughter and the daughter
  had refused to let the staff member assigned put
  her father on.
•  

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Decreasing Dialysis Patient-Provider Conflict
(cont.)A QI Approach Examples

• 3. Discuss and choose interventions that will
  address any patterns.
• The QI committee directed that more experienced
  staff stick new AVFs. The DON was assigned to
  implement this change.
• The staff member was recommended for training in
  conflict management using the interactive
  training module in the DPC Toolbox and to be
  assigned to a mentor and have his cannulation
  skills assessed. The DON was assigned
  responsibility for the training and the charge
  for the mentoring and cannulation assessment.
• A family conference was advised where the family
  would be informed of the actions and the daughter
  would be asked to voice any complaints to the
  charge nurse away from the treatment area. The SW
  was assigned the responsibility of setting up the
  conference.
•  4. Upon review for improvements the next month,
  the number of conflicts had been successfully
  decreased.

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Quality Improvement Training

• Preparation Materials Needed
• Enter information on Conflict Logs
• Clarify details with staff, if needed
• Confer with others regarding types and causes
  of conflict, if needed
• Plot Data Graphs
• Schedule QI Committee meeting
• Prepare meeting room

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Quality Improvement Training

• Conduct First Leadership Meeting
• Review DPC data
• Discuss
• 1. Any trends observed
• 2. New interventions needed
• 3. Staff training needs
• A. Veteran staff- Follow up for
  understanding
• B. New staff - Initial orientation
• C. Retraining of staff for problem behaviors
  and attitudes
• 4. Individual patient issues to be addressed
  during patient care
  conferences

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Quality Improvement Training

• Time Required
• Variable 1-3 hours
• Monthly or quarterly (minimum) data activities
• Preparation /Material Needed
• Data preparation activities
• Collect Tracking Tool documentation forms

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DPC Series Wrap-upSix Steps to Resolving
Conflict

• 1. Share your feelings
• 2. Define the problem
• 3. Explore options. Look for possible
  solutions to the problems of both parties
• 4. Select and negotiate one option to work on
• 5. Take action
• 6. Get feedback

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DPC Series Wrap-upImportant Tips for Defusing
Anger

• Breathe Deeply
• Remove Yourself
• Reframe the Situation
• Ignore Personal Attacks
• Exercise Regularly
• Violence is Unacceptable

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Quality Improvement

• In Conclusion
• .embrace the voice of CMS and the ESRD
  community in their directive to ensure that
  patients and providers in dialysis units are able
  to resolve the issues of conflict and improve the
  quality of care for all patients..

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Thank you from Cecilia Connie
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Additional Resources

• DPC Tip Sheet 2 - Staff Training Modules
• DPC Tip Sheet 1 - Administration
• www.esrdnet17.org
• www.esrdnet15.org
• Developed by ESRD NW15

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CEU Requirements

• EVALUATION!
• Evaluation forms can be found on NW 17 or NW 18
  websites under
• CEU Evaluation for DPC WebEx Session 5
• www.esrdnet17.org
• www.esrdnetwork18.org
• You must attend all 5 sessions to receive CEU
  credit!
• Please return completed evaluation forms by fax
  to
• Social Workers - NW 17 [phone]
• RNs - NW 18 [phone]