What did we do?
We took an ethnographic approach to evaluate two different quality improvement (QI) initiatives, which aimed to improve the identification and reduce the number of cases of Acute Kidney Injury (AKI), at two secondary care hospital providers.
The AKI initiative at Hospital X used the Institute for Healthcare Improvements (IHI) Break Through Series collaborative approach, meaning that AKI was 'everyone's problem' for the participating wards (we also supported the delivery of this work). The QI work at Trust Y was designed around two specialist AKI nurses acting as ‘change agents’, combined with an IHI-informed programme of system redesign. The specialist nurses were responsible for supporting staff from all wards that provide care for people with AKI.
Why is it important?
AKI is a clinical syndrome characterised by a sudden reduction in kidney function that complicates episodes of acute illness. It is common, harmful and costly and is a major barometer of patient safety across the NHS. We know that AKI increases mortality in the short to long term, in the UK, up to 100,000 deaths each year are associated with AKI. Up to 30% of these deaths could be prevented with the right care and treatment (NCEPOD, Adding Insult to Injury, 2009).
What did we find out?
Both Trusts reported notable successes against key process and outcome targets in the management of AKI. To achieve this, they both sought to capitalise upon the mandatory introduction of an AKI alerting system as a means to formalise existing work within each organisation.
The Hospital X improvements were primarily driven by the introduction of the AKI alert, the launch of the collaborative programme, the development of the process to achieve compliance with the bundle, and an online educational programme. The Hospital Y improvements were driven by the introduction of the AKI alert, the employment of two full time AKI nurse specialists, the development of the checklist, and the hospital-wide education and awareness programme delivered by the nurse specialists. In both sites, these components were developed iteratively and over a considerable period of time.
Though the hospitals adopted different approaches to AKI improvement, comparative analysis illuminated common tensions and trade-offs. The differences lay in how each hospital negotiated these challenges in order to implement an AKI alerting system to improve process and health outcomes. Overall, there was a general tension between maximising benefit whilst minimising additional burden for patients and healthcare staff in a period of increasing austerity.
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Understanding context in quality improvement: Ethnographic hospital case studies of AKI improvement initiatives - Lynn Sykes, Clara Weisshaar, Tom Blakeman, Simon Bailey & Adam Brisley