Table 4.

Barriers to QI program implementation, responsive changes, and future recommendations

Identified Barriers (pre- and intraprogram)	Responsive Changes		Remaining Barriers (postprogram)	Future Recommendations
Program eligibility criteria and enrollment
[Pre-] Eligibility threshold of eGFR <20 ml/min per 1.73 m2 felt to be too restrictive and could lead to missed opportunities for early education		Changed threshold to eGFR <25 ml/min per 1.73m2	[Post-] Eligibility threshold of eGFR <25 ml/min per 1.73 m2 identified some patients for whom nephrologists thought vascular access planning premature, and some patients were reluctant	Continue to alert nephrologists to patients with eGFR <25 ml/min per 1.73 m2 to prompt consideration
				Use referral to modality-education class as trigger to enroll patients in the vascular access program
[Intra-] Nephrologists wanted to speak to patients about vascular access before navigator contacting patients		Ensured that navigators contacted nephrologists before approaching patients about program enrollment
[Intra-] Difficult for navigators to meet in person with nephrologists to discuss program-eligible patients		↑ EHR message use and ↓ in-person meetings	[Post-] Paper notices improved communication/provider awareness, but more communication needed	Obtain stronger nephrologist buy-in preprogram
		Placed paper notices on exam room doors of eligible patients to remind nephrologists to discuss		Give medical providers access to electronic dashboard
Vascular access–specific patient education
[Pre-] Need for standardized education		Developed education session facilitator guide	[Post-] Patients and care partners desired supplemental education video and more patient testimonials	Develop video to complement written materials
				Encourage use of peer mentoring program
[Intra-] Need for supplemental resources		Developed handout with resource weblinks
[Intra-] COVID-19 pandemic interrupted in-person education sessions		Shifted to telephone-based education sessions
Peer mentoring
[Pre-] Concern that a national peer mentoring program (with mentor telephone access) would not be used		Developed local peer mentor program	[Post-] Mentor training did not have enough time for mock mentee interactions	Increase time for peer mentor training
		Tailored program to vascular access by equipping mentors with lists of common barriers to vascular access care and frequently asked questions
[Intra-] Need for vascular access education for mentors		Developed vascular access education “refresher” that was provided to mentors before mentee matching	[Post-] One mentee did not “match” with a mentor	Add option to participate in a national peer program
Needs and barriers assessment
[Pre-] Potential overlap with existing needs assessment		Adapted existing assessment to incorporate barriers relevant to vascular access and established thresholds of responses for resource provision
Vascular access care navigation
[Pre-] Concern about a heavy workload for navigators		Trained three clinic personnel (case managers, nurses) so duties could be shared, and back-up provided	[Post-] Duties can be time consuming if added to additional non-navigator job responsibilities	Incorporate vascular access navigator responsibilities with those of a CKD navigator (1 FTE)
Vascular access–specific electronic dashboard
[Intra-] Difficult and time consuming to prioritize potentially eligible patients		Created filters by which list could be sorted (eligible, ineligible, need further review, etc.)	[Post-] Only the navigators used the dashboard	Give medical providers access to dashboard

Barriers were ascertained from pre-, intra-, and post-QI program implementation interviews with patients, care partners, medical providers, and clinic personnel participating in the program. [Pre-], [Intra-], and [Post-] denote timing of barrier identification. QI, quality improvement; EHR, electronic health record; COVID-19, coronavirus disease 2019; FTE, full-time equivalent.