[An example of successful systematic improvement work. Process management improved routines and simplified dialysis...

In the care of patients with end-stage renal disease in need of dialysis at our hospital we found that only 50 per cent of the 199 patients who started hemodialysis during 1995-96 had a functioning vascular access, predominantly in the form of a matured arteriovenous fistula. Although these findings were presented at departmental meetings and improvement was deemed essential, the situation persisted according to a new survey in 1998. The problem was therefore selected for an improvement project within the framework of process management. Through root cause analysis with data collection and subsequent application of the Plan-Do-Study-Act cycle, a team demonstrated that the cause was not, as previously believed, delays in bringing these patients to surgery. Instead it stemmed from a lack of consensus about when to initiate preparations for dialysis, and from insufficient analysis of how patients' renal function declined over time. Therefore the decision to prepare for dialysis was generally made far too late. With new guidelines for determining when to start preparations (at a renal creatinine clearance of 15-20 ml/min), provision of a diagram-sheet for plotting 1/S-creatinine in each patient's file (to facilitate monitoring of the decline in renal function over time), and continuous feedback to department physicians on performance, the proportion of patients who started hemodialysis with a proper access approached 100 per cent.