Tuesday, 16 November 2010

Patient activation, staff morale and outcomes

Good kidney care has always been based on teamwork. The complexity of renal failure, the wide range of treatment options – from an ABO incompatible live donor transplant or daily dialysis to conservative care requires detailed knowledge, precision and technical skills. The impact on physiology, diet, psychological wellbeing and social functioning brings added dimensions to kidney care. Achieving optimal outcomes and improving patients’ experience of care depends on the whole range of skilled and motivated individuals needed to manage different aspects of kidney care; but it also needs individual practitioners to work together and with patients as a multiprofessional team. No one group, single practice or characteristic can make a major difference on its own. A holistic approach including attention to supporting patients, staff working climate, inter-professional respect and integrated practices are required to provide holistic care.

A recent paper from the USA (Dialysis Practices that Distinguish Facilities with Below – versus Above-Expected Mortality by Brennan, Spiegel and colleagues Clin J Am Soc Nephrol 5: 2010. doi: 10.2215/CJN.01620210). Found that dialysis units with below expected mortality reported that patients in their units were more activated and engaged, physician communication and inter-personal relationships were stronger, dietitians were more resourceful and knowledgable, and overall coordination and staff management were superior when compared with units with above expected, worse, mortality. Staff rating of these practices explained 31% of the variance in mortality in the kidney units studied.

It would appear that dialysis staff know if their unit is performing well. I bet patients would also be able to tell us what works well and what needs to be improved. When patients are more willing to learn, independent and engaged, survival is better. This suggests that measuring patient activation scores might provide ideas for potential interventions that increase motivation, personalise care and participation in decision making. The “patient activation model” shows that patients who are informed and actively participate in their healthcare have better outcomes than patients who are inadequately informed, unmotivated or passive.

It was interesting that Spiegel and colleagues found that inter-personal relationships and communication, willingness to spend time with the dialysis staff and frequent and timely multi-disciplinary care conferences, particularly when patients had recently been discharged from hospital, were highly predictive of good outcomes whereas physicians’ technical skills or knowledge were not predictive at all.

Top performing facilities were more staff orientated and had friendlier environments, had better management and higher quality continuing education programmes than the units with worse outcomes.

We have always believed that multiprofessional team working is the key to good outcomes in kidney care, now we have evidence to support that belief. The paper also provides some insights and methodologies we could apply in the UK to understand patient activation, staff morale and team working better so that we could learn from the best and improve patient experience and survival.