Lizzy Bovill, Programme Manager, The Modernisation Initiative
Rosamund Tibbles, RGN, BSc, Senior Nurse for Service Improvement, The Modernisation Initiative
Katie Vinen, MD, Consultant Nephrologist, King’s College Hospital
Cormac Breen, MD, Consultant Nephrologist, Guy’s and St. Thomas’ Hospital

***Watch a video clip of the Modernisation Initiative's improvement work shared at IHI’s 19th Annual National Forum.***

To increase patient choice by establishing a haemodialysis self-care education programme and to increase capacity by managing the demand better through stratifying the patient population. The aim was for at least 10 percent of patients to become fully independent by December 2007.

• Number of patients approached for inclusion in the self-care education programme
• Number of patients who have declined or who are unable to participate in self-care, often due to extreme frailty
• Number of patients achieving partial independence: Patients participating in self-care and achieving partial independence with their haemodialysis treatment
• Number of patients achieving full independence: Patients who are fully self caring and independent with their haemodialysis treatment

The Modernisation Initiative worked in partnership with the renal centres at King’s College Hospital and Guy’s and St. Thomas’ Hospital (London, UK) to introduce a self-care programme for haemodialysis (HD) patients. Haemodialysis provides life-sustaining treatment for people with chronic kidney disease (CKD); as patient numbers have risen, teaching has taken second place to throughput and patients have become passive recipients of care.

A self-care programme was initiated to increase independence, offer patients more choices in terms of treatment options, and to stratify the patient population to manage demand better. Self-care is about individuals taking responsibility for their own health and well-being. This can include healthy living and prevention of illness as well as participating in the self-management of a health condition such as chronic kidney disease.

Self-care in haemodialysis (HD) specifically involves learning how to perform some or all of the physical tasks associated with HD such as preparing the equipment, measuring weight and blood pressure and self-cannulation. It also includes learning other aspects of disease management such as coping with dietary and fluid restrictions, looking after your heart and managing medications.

Specific changes tested include the following:

• Conducted a patient survey to assess current and aspirational levels of self-care
• Identified two HD units to stratify the patient population and pilot self-care
• Established an education programme for staff around self-care teaching skills
• Established an information programme for patients around the benefits of self-care
• Scored the individual patients’ self-care levels using a 14-point assessment tool
• Developed a competency based training guide
• Initiated self-care education using one-to-one and group teaching
• Collected monthly data to measure progress
• Rolled out self-care education programmes in nine other HD units
• Developed further tools to support teaching using a PDSA approach
• Established learning sets to embed self-care into practice

Almost 10 percent of HD patients are now completely self-caring and we anticipate reaching our 10 percent goal by December 2007; a further 50 percent are self-caring to some degree resulting in greater patient choice in terms of treatment options and increased unit capacity. The culture in HD units has moved from almost complete dependence to partial independence, patients are expressing higher levels of satisfaction and staff are reporting higher levels of treatment concordance.

Lessons Learned:

• Create a vision and identify clear benefits to encourage patient involvement in self-care
• Utilise patient-to-patient peer support and patient champions to "market" self-care
• Develop a collaborative approach to teaching with staff and patients
• Encourage the staff and patients to develop their own strategies for teaching, do not impose a strategy
• Create a streamlined process to ensure capacity is used efficiently
• Expect small steps; be patient and do not lose the momentum
• Engage the key staff at the outset and involve the whole of the multi-professional team
• "Train the trainers": Staff need support to develop teaching skills and confidence in teaching
• Effective leadership is key to success and needs to be supported
• Celebrate success and learn from failure
• Spread and share the learning

Rosamund Tibbles, Senior Nurse for Service Improvement
The Modernisation Initiative
South Wing Link Corridor
St. Thomas’ Hospital 
Ros.tibbles@gstt.nhs.uk
www.mykidney.org.uk

[Posterboard presentation at IHI's December 2007 National Forum]