"Using a System View to Conduct a Care-Transitions
Quality Improvement Project in a Nephrology Practice"
CMS (Centers for Medicare and Medicaid Services) recognizes that deficiencies in providing medical
care across a gap not only results in poor patient outcomes but also costs many billions to US
taxpayers annually. This has resulted in the recognition of an opportunity to improve medical care
systems in the area now known as "Care-Transitions". In earlier work, this team has used quality
improvement techniques toward better outcomes for patients during the first 90 days of outpatient
hemodialysis care, where the mortality rate is known to be extremely high. The system of care has
been defined using a System Linkage Map (SLM) and several projects have been nested under this
overall goal of reducing first 90 day mortality. The current project used the AMI to define objectives
involved in proper Care-Transitions across the gap in care between a hospital and an outpatient
dialysis facility. Selected objectives are now actively being pursued using PDSA Cycles on both
sides of this gap in care. The background concepts, SLM, use of AMI and the current PDSA Cycles
will be discussed.