Abstracts

The management of people on dialysis is complex andrequires a multi-disciplinary multi-professional approach.Observational studies in dialysis care have demonstrated acorrelation between key clinical indicators and survival. However,achieving change in such a complex setting is difficult, withlimited evidence from controlled studies of the effectiveness ofinterventions to improve these indicators. There is littleevaluation of how best to implement and sustain known best practiceinto clinical care. UK renal registry data shows that whilstoverall standards have improved, variation between units remainsunchanged. This variation demonstrates that feedback alone is notenough to implement best practise, and that it is also necessary tounderstand cultural, structural, organisational and processfactors.Quality Improvement (QI) is the process by which change canbe implemented in systems. Methodologies vary, and highlight theneed for bespoke approaches tailored to fit the clinical context.In 2010 the Salford Royal renal network introduced a two-yearprogramme of QI to improve clinical indicators in dialysis care.Results were followed up on completion of the programme toestablish whether outcomes were sustained. This thesis starts witha literature review summarising the evidence to date on modifiablefactors affecting outcomes in renal replacement therapy and therationale for addressing these factors in our chronic dialysispopulation, the development of QI in healthcare, and the evidencefor its use to improve outcomes in renal replacement therapy.Thefirst aim of this thesis was to analyse the outcomes of the Salfordquality improvement programme. This found that the programme wassuccessful in improving attainment of clinical indicators, andthere was evidence of a reduction in hospitalisation and itsassociated costs. The second aim was to analyse in more detail oneaspect of the programme- reduction in peritonitis. Key themes thatemerged from this were the role of audit and continuousmeasurement, the importance of local leadership, learning from bestpractice elsewhere, and a patient-centred approach to reducingavoidable harm. The last question centred on the sustainability ofresults. Review of two years follow up data on urea reductionratio and bacteraemia identified that whilst not all changes topractice were sustained, both improved clinical outcomes werebroadly sustained. However, additional themes emerged from theanalyses, highlighting the need to embed ongoing continuous reviewinto practice. Finally, I have described potential future workarising from this thesis.Advisors/Committee Members: HEGARTY, JANET J, Kalra, Philip, Hegarty, Janet.