Over the last few months, the Measurement and Understanding workstream have been identifying and collecting information on identified measurement tools that could be used within quality improvement projects in the renal setting. When initially embarking on this project, we decided we wanted measurement tools that were relevant to renal patients; rigorous and valid providing accurate measurement; and relevant to quality improvement interventions and projects.
We started with developing a proforma, to structure the information collected on each measurement tool. We identified suitable measurement tools that we were individually aware of, that could be used within renal quality improvement. We then used this proforma to assess each tool to decide whether it was suitable and relevant to include in the KQuIP hub. This also allowed us to pilot the proforma and identify if it provided the information required. Pilot work always surprises me, as you think you have it right the first time, but real life always produces unpredicted barriers or questions. Reality reminded yet again of the importance of pilot work, as on version 4, we finally had a proforma and information that we felt did justice to the tools and the information on the KQuIP hub.
We have initially provided information on 7 measurement tools relevant to renal quality improvement projects. This covers an inclusive multi-disciplinary approach, including tools identified by physiotherapists, dieticians, a health economist and haemodialysis practitioners, with strong guidance from our patient representative, as to the relevance of the tools. The 7 tools identified and their relevance to renal quality improvement are:
- Dukes Activity Status Index (DASI) – This provides a simple questionnaire for patients to complete that reflects their physical function. The DASI score can be used to assess quality improvement interventions designed to improve patients’ functional capacity or increase their level of activity. In my own unit in Derby, we used the DASI score to assess the impact of a QI programme to promote patients increasing their exercise activity and increase staff awareness of the importance of this for kidney patients. The DASI score demonstrated that this did translate into improved activity levels for patients. Other aspects of the project identified that nursing staff awareness had the biggest impact on promoting activity in haemodialysis patients – a change which has been sustained within our nursing team. Further information on the DASI score can be found here.
- GPPAQ questionnaire – This is similar to the DASI score, in that it can be used to assess physical activity levels, but also used to identify those patients who may need encouragement to increase their activity. This can also be used to identify suitable patients for a quality improvement intervention around increasing activity in kidney patients, as well as measure the impact of the intervention. Further information on the GPPAQ questionnaire can be found here.
- Renal Dietetic Outcome tool – This is a document and plan developed by the Renal Nutrition group, outlining (among other things) what are the important nutritional outcomes to assess for kidney patients. This is aimed at renal dieticians, but the measurement strategy could provide focus for any quality improvement project aimed at nutrition or diet for kidney patients. Further information on the Renal Dietetic Outcome tool can be found here.
- EQ-5D-5L tool – This is a questionnaire designed to measure health-related quality of life. It can measure this across disease groups. It is most well known as one of the measures used within the Transforming Participation in CKD project and can be used to assess the impact of interventions to improve health-related quality of life. Further information on the EQ-5D-5L can found here.
- Blood volume monitoring – This is a tool used on haemodialysis machines to assess how well patients’ are tolerating fluid removal during haemodialysis treatments. Whilst this tool can be used to assess interventions related to fluid status of haemodialysis patients and fluid removal during haemodialysis, it can also be used within quality improvement to improve the patient’s experience of haemodialysis. Within in Derby, this was one tool we used to reduce low blood pressure during haemodialysis treatments, as demonstrated in this case study. Further information on blood volume monitoring can be found here.
- Body Composition Monitor (BCM) – This measure is also related to the fluid status in haemodialysis patients and is currently being used within the BISTRO trial. Again it can be used within quality improvement projects and interventions related to fluid status of kidney patients. Further information on body composition measurement can be found at here.
- Haemodialysis Trigger Tool (HTT) –This allows measurement of harm events during haemodialysis and has come from one of my own quality improvement projects. Within my unit, Derby renal unit, we used monthly HTT monitoring to identify where we needed to focus quality improvement projects and then assess the impact of interventions to improve harm events. Further information on this can be found in the haemodialysis trigger tool case study found on the KQuIP hub. Further information on the haemodialysis trigger tool can be found here.
This is by no means an exhaustive list, but the start of this work. We are going to continue to explore and add to this information, looking at data sets for various potential project areas, as well as continuing to include further relevant measurement tools we identify. However, we would also like inspiration from outside of the Measurement and Understanding workstream. We have inserted a blank proforma onto the KQuIP hub and if you have a measurement that you think should be included, please complete the proforma found here and send it to the workstream via Katie.Fielding@nhs.net. We will then review the tool for consideration to be added to the KQuIP hub. Only by sharing our work and differing perspectives, can we truly progress quality improvement within the renal community.
One final thought about what I have learnt from this process. When asked to chair the measurement and understanding workstream, I will admit I was a little confounded as to why they would want me, a haemodialysis nurse to do this. This project has taught me what I bring as a nurse. I was familiar with or understood every tool brought to the workstream. Whilst other professions had more in-depth expertise on their own tools, they did not have this scope of awareness.
One of my colleagues in Derby often cites that nurses treat the patient, rather than a condition, disease or specific outcomes, travelling on the journey with the patient through their kidney disease for many years. This puts nurses in a unique position to help understand what is relevant to kidney patients (alongside the patient’s own perspective) and what will make a difference within clinical practice, an essential element of quality improvement. I would urge those who are undertaking quality improvement, to not just use nurses as data collectors, but include their unique perspective in developing a rounded, practical and useful quality improvement project. And nurses – don’t be scared to speak up – you have a breadth of knowledge and experience that gives you something very valuable to add to quality improvement projects.