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Quality Improvement

One of the primary objectives of ESRD Networks is to improve the quality of health-care services for ESRD patients. Click a link below for additional information:

Adequacy/Access Project Fluid Management National Elab Report Transplant Resources
Anemia Management Immunizations PD Adequacy Project Water Wise Project
Chronic Kidney Disease (CKD) Improving Albumin QAPI Resources Webinar Recordings
Dialysis Facility Reports (DFRs) Increasing AVF Quality Incentive Program (QIP)  
Fistula First/NVAII Project Infection Control Toolkits  

 

CMS Quality Incentive Program (QIP)

The ESRD Quality Incentive Program (QIP) is a pay-for-performance initiative designed to encourage the delivery of high-quality services in dialysis facilities. Below are resources related to the QIP.

Quality Incentive Program Resources
Official CMS Website for ESRD QIP - Contains a wealth of information including an Educational Resources page
CMS email for QIP Questions from Facilities
Final Calendar-Year 2014 Rule for ESRD Prospective Payment System- (pdf - 186 pgs) - Large File
National Healthcare Safety Network Information (NHSN)

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Infection Control

Infection Control Tools
Six Tips to Prevent Dialysis Infections - Pocket Guides for Patients (from the CDC)
CDC Resource Toolkit to Help Reduce Dialysis-Related Infections (pdf - 21 pages) - Includes some resources in Spanish
CDC Dialysis Safety Website - Contains staff and patient resources to assist in reducing healthcare associated infections and to improve patient safety
Infection Control Requirements and Clarification Regarding Guidance on Parenteral Medication Vials (pdf)
Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients - This guideline from 2001 is cited in the Conditions for Coverage
Complying with OSHA's Bloodborne Pathogens Standard (pdf - 2 pgs)
Infection Control Web Recordings

Lunch n Learn Webinar Covering CDC Resources to Reduce Infections - (32 mins) Presented by Network #15

NHSN Dialysis Event Reporting WebEx - (57 minutes) Presentation by Tamara Hoxworth, Ph.D. on behalf of Network #15

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Quality Assessment and Performance Improvement (QAPI)

Regulation V626 of the 2008 Conditions for Coverage for ESRD Facilities contains a requirement for “facilities” to develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. Specific areas the dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement include: adequacy of dialysis, nutritional status, mineral metabolism and renal bone disease, anemia management, vascular access, medical injuries and medical error identification, reuse of dialyzers, patient satisfaction, and infection control. Frequent review and trending of outcomes with development of improvement plans when appropriate are indicators of an effective program.

QAPI Resources
QAPI Toolkit - (pdf - 48 pgs)
QAPI Related V-Tags - (pdf - 12 pgs)

The QAPI modules below are self-paced QI educational tools to help facilities with basic quality improvement concepts to create an effective QAPI process.

Quality Assessment and Performance Improvement (QAPI) (WRF recording) 64 minutes –- A presentation by Network 15’s Quality improvement staff.  Topics covered in module 1: What is QAPI, review of Conditions for Coverage (CfC) and V-tags related to QAPI, contents of the QAPI toolkit mailed to participating facilities, and how to run an effective QAPI meeting.  Module 2:  A project example, how to evaluate your data, a practical review of rapid cycle PDCA and AIM for improvement models, and putting tools and resources to use when designing a project.

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Water Wise Project

Water Quality and Dialysate for the Physician (Water Wise Project) (WebEx Recording 79 minutes) - A presentation by Danilo B. Concepcion CCHT, CHT, CBNT, designed for Medical Directors but also a valuable review for all dialysis staff members involved in monitoring their facility water treatment system.  Includes a discussion of Medical Directors’ responsibilities as outlined in the Conditions for Coverage (CfC), and a review of Association for the Advancement for Medical Instrumentation (AAMI) guidelines.  The various components involved with dialysis water treatment are reviewed.

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PD Adequacy Project

According to the International Society for Peritoneal Dialysis (ISPD) Guidelines, a randomized prospective study by Lo et al. demonstrated that a total weekly Kt/Vurea< 1.7 is associated with poorer primary or secondary outcomes, i.e., more clinical problems, a greater need for erythropoietin therapy, and poorer patient technique survival.  The current ISPD recommendation for PD adequacy in adult patients is a total weekly Kt/Vurea of > 1.7.    Additionally, it is recommended that adequacy measurements be performed at least every 4 months and at specified intervals if problems occur.  This project measures completion of testing at the recommended frequency and the % of patients meeting the 1.7 Kt/Vurea target.

PD Adequacy Resources

Sample Welcome Letter to PD Patients (Word Doc)

Peritoneal Equilibration Test (PET) Procedure (Word Doc)
Fast PET Procedure (Word Doc)
PD Adequacy Urine Collection Flowchart - (Word Doc)

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Transplant Resources

The Conditions for Coverage require that facilities track the results of each kidney transplant center referral, monitor the status of patients on the transplant wait list, and communicate with the transplant center annually as well as when/if there is a change in patient status.

Feel free to modify the tools below to make them work in your facility.

Transplant Communication Toolkit

Policy and Procedure Template - The Conditions for Coverage require that your communication with the transplant providers be “systematic and documented”. Emplacing an explicit Policy and Procedure that outlines what must be communicated, when, and by who will help your facility meet the requirements of the State Survey, as well as providing you and your staff with a simple and concrete reference regarding how the communication tasks are to be addressed.

Waitlist Tracking Tool - Allows you to track patient names, statuses, and transplant provider contact information in one location.

Transplant Event Reporting Worksheet (MS Excel) - Developed in consultation with the transplant providers. Includes all of the events and information that they need to keep their records current and functional. Add your transplant center’s specific phone and fax information to make this even easier to use.

Patient Transplant Information Page (MS Word)- This form should be placed in a patient’s chart to gather all contact information for the various clinicians involved with the care of the patient, including their transplant provider(s) and their current transplant status.

Patient Transplant Contact Card (MS Word)- Template for a wallet-sized card that puts contact info for physician, transplant provider, and dialysis unit all in one place, as well as listing some of the common events that need to be reported to the transplant provider.

Condition for Coverage: VTAG 561 - Outlines the dialysis facilities’ responsibilities for tracking and communicating the status of transplant patients

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QI Form Template
The following documents can be used as guidelines for deciding on and implementing Quality Improvement Projects.

Generic QI Template (pdf - 4 pgs)

QI Project Examples, Root Cause Assessments, and Resources:

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This link will take you to the national  Fistula First website.    Fistula First - NVAA Project

Resources
Web site Links
Network #15 Reports


 

Overview
The National Vascular Access Improvement Initiative (NVAII) is a nationwide campaign to increase the use of arterial venous fistulas (AVF). Also known as the "Fistula First" initiative, the mission is to make sure that ESRD patients receive his/her optimal form of vascular access (in the majority of cases AVF) and to avoid vascular access complications. Network #15 has emphasized improved communication between the nephrologist, the vascular surgeon, the interventional radiologist, and dialysis staff.


Resources for Achieving Fistula First Goals
 
Fistula First Change Package Overview (pdf) - Lists 11 key strategies for increasing AV fistulas.
Video of Arteriovenous Fistula (AVF) Cannulation - This video can be viewed from the Fistula First Web site.
Patient Education Resources Notebook (pdf - 6 pgs) - This pdf document contains links to a variety of resources regarding vascular accesses and AV fistulas that can be downloaded and provided to patients.
Creating AV Fistulas in all Eligible Hemodialysis Patients - A Continuing Medical Education presentation. Learn the fundamentals of placing AV Fistulas and surgical strategies for successful placement.
Videos Answering Common Questions from Patients Regarding AV Fistualas - from the Fistula First Website, each video is less than 2 minutes long.
Example QI Project for Decreasing Central Venous Catheters / Increasing AVFs
 

Change #1: Routine CQI Review of Vascular Access
Preventing Central Venous Catheter Infections (pdf)
Vascular Access Coordinator Role (pdf)

Change #2: Timely Referral to Nephrologist
Nephrologist Letter to Primary Care Physician (MS document)
Pre-ESRD Planning Algorithm (pdf)
Change #3: Early Referral to Surgeon for "AVF Only" Evaluation and Timely Placement
Hemodialysis Access Referral Form: New Access (pdf)
Change #4: Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services
Universal Vascular Access Diagram (pdf)

Change #5: Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement
Vessel Mapping Protocol
(pdf)
Autologous AV Fistula Algorithm
(pdf)
Physical Examination of Dialysis Vascular Access (pdf - 20 pgs) - Developed by Network #14 in collaboration with Gerald Beathard, MD.
A Practitioner's Resource Guide to Hemodialysis AVFs
(pdf - 21 pgs) - Developed by Network #14 in collaboration with Gerald Beathard, MD.

Change #6: Secondary AVF Placement in Patients with AV Grafts
Hemodialysis Access Referral Form: Existing Access
(pdf)
Sleeves Up Protocol
(pdf)

Change #7: AVF Placement in Patients with Catheters Where Indicated
AVF Functionality Tool (Interactive Excel Spreadsheet)
Catheter Reduction Toolkit
Management of Patient with CVC Algorithm
(pdf)
Physician Letter to Catheter Patient
(pdf)

Change #8: Cannulation Training for AV Fistulas
How-to Manual: The Art of Teaching Buttonhole Self-Cannulation (pdf)
Policy and Procedure for Cannulating New Fistulas
(pdf)
Self-Cannulation of Fistulas Patient Policy and Procedure
(pdf)
Self-Cannulation of Fistulas Staff Policy and Procedure
(pdf)
Training Checklist for Self-Cannulation
(pdf)

Change #9: Monitoring and Maintenance to Ensure Adequate Access Function
Bruit Audio Clips - from the FistulaFirst.org Website - Scroll down to the bottom of their page and find "Listen for the Bruit"
KDOQI Summary Guidelines Section II - Monitoring, Surveillance, and Diagnostic Testing
(pdf)
Vascular Access Referral Intervention Log
(pdf)
Vamp© Vascular Access Monitoring & Surveillance Flow Chart
(pdf)

Change #10: Education for Caregivers and Patients
Conquering Your Fistula Fear (pdf)

Have More Control Over Your Dialysis and Health
FAQ about Arterial Venous Fistula's (AVF)
Fistula Preservation, Development, and Maintenance
(pdf)
Arterio Venous Fistula Brochure for Patients (pdf 2 pgs)



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Web sites with Fistula First Resources
American Society of Diagnostic and Interventional Nephrology (ASDIN) -
A principal goal of the society is to increase fistula use and this site includes online training videos as well as links to hands-on training programs for diagnostic interventional Nephrology.
FistulaFirst.org - This web site provides comprehensive information and tools about the Fistula First project. It also has a link to the video training program developed by Dr. William Jennings and Dr. Lawrence Spergel for surgeons and interventionalists. 10.5 AMA/PRA Category 1 credits are available upon completion of this training program.
Vascular Access Society - This web site has detailed guidelines for vascular access which include diagrams for placement and management of AV Fistulas, as well as a vascular access forum.

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Increasing Arteriovenous Fistulas (AVF) Within Network #15

The primary objective of this project was to increase the placement of AVF within the adult, in-center hemodialysis population in Network #15. In accordance with the NKF-K/DOQI Vascular Access Workgroup recommendations, facilities, surgeons, and nephrologists were encouraged to achieve a 50% or higher fistula placement rate in incident (new) patients, and a 40% or higher fistula placement rate in prevalent (existing) patients. Patients at facilities within and outside Network #15 have matched and greatly exceeded these rates, so we knew the goal was attainable.

Key features of this project included:

  • Visiting key nephrologists and surgeons in the community, educating them about the importance of fistulas, sharing information about the project, and promoting a team effort.
  • Sharing surgeon-specific data on access placements, allowing surgeons to see how their practices compared to their peers.
  • Organizing educational events with nephrologists, surgeons, and nurse educators to present different perspectives on fistula placement.
  • Presenting "Change Packets" that contain resource materials for surgeons, nephrologists, facility staff, and patients.
  • Developing a simple vascular access tracking system that allows facilities to track surgeon-specific information (if they wished to continuing generating surgeon-specific information at the end of the project).
Tools for Increasing Arteriovenous Fistulas
AVF Functionality Tool (Excel Spread sheet)
Patient Handout - Caring for Your Fistula (PDF - 2 pgs)
Patient Handout - Caring for Your Fistula (Spanish language) (PDF - 2 pgs)
Patient Handout - Fistula Exercises (PDF - 10 pgs) This handout can be made into a booklet by converting these single-sided pages to double-sided pages (using a copier) and folding.
Summary of NKF-K/DOQI Vascular Access Guidelines -2000 Update (PDF - 2 pgs)
Billing Rules for Non Invasive Vascular Studies - (PDF - 3 pgs)
Vein Mapping Procedure from Olympic Vascular Lab (PDF - 4 pgs)
Sample Letter to PCPs and/or Insurance Companies (PDF - 1 pg)
Job Description for Vascular Access Nurse Coordinator/Case Manager (PDF - 2 pgs)
Example QI Project for Decreasing Central Venous Catheters / Increasing AVFs

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Chronic Kidney Disease (CKD)

CKD Resources
For People with Diabetes or High Blood Pressure: Get Checked for Kidney Disease (pdf) from NKDEP
Diabetes & High Blood Pressure Make the Kidney Connection, What African Americans Need to Know
Provider CKD Information Tool (pdf - 1 pg)
Explaining GFR - How Your Kidneys Work - (pdf) Spanish Version (pdf)
National Kidney Disease Education Program (NKDEP) - Website contains materials and info for both patients and healthcare professionals

You Have the Power to Prevent Kidney Disease: A health education video from NKDEP

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Immunizations

Immunization Resources
Sample QI Project: Improving Immunization Rates (pdf - 5 pgs)
Vaccine Immunization Record for Adults (pdf)
Who is at High Risk of Flu Complications? (English) - Spanish Version (pdf)
People with Chronic Conditions Should Get a Flu Shot Poster (English) - Spanish Version (pdf)
Standing Orders for Flu Vaccines (pdf)
Healthcare Personnel Vaccination Poster (pdf)

Adult Immunizations - Info on the CMS Web site for both providers/caretakers and patients.

Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease (pdf)
Immunization Education Resource Book - (pdf -285 pgs ) This resource book is very large so may take considerable time to download. It contains a variety of materials including: a step-by-step guide to adult immunizations, immunization record sheets, posters, handouts, brochures, newsletters, fact sheets, and more.

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Ongoing Quality Initiative - Improving Albumin Levels

Results from annual CPM collections indicate that Network #15 has an opportunity to improve albumin rates for adult, in-center hemodialysis patients. Ideally, at least half of dialysis patients should have a mean serum albumin > 4.0 gm/dl BCG, or > 3.7 gm/dl BCP. This goal is currently being met in 20% of Network #15's facilities so we know this is an achievable target. The challenge is for every facility to hit that mark!

The resources below (previously mailed to all facilities) may be helpful in achieving higher albumin levels:

Patient/Family Educational Materials for Increasing Albumin
Albumin: Why is it Important? (PDF - 1 pg)
In Control Newsletter - Protein: An Important Part of Your Dialysis Diet (pdf 4 pgs) Reprinted with permission from Life Options.
Live Longer with a Higher Albumin (PDF - 1 pg)
Promoting Protein (PDF - 2 pgs)
Protein Packed Snacks (PDF - 3 pgs)
Increasing Your Protein Intake isn't as Hard as you Think (PDF - 10 pgs)
Protein Calendar - 30 Ways to Increase Your Protein (PDF - 1 pg)
Kid and Kidney-Friendly Foods (PDF - 2 pgs)

Staff Resources for Increasing Albumin
QI Project Example: Increasing Albumin Levels (pdf - 4 pgs)
2000 NKF-KDOQI Nutrition Guidelines (highlights) (PDF - 1 pg)
Improving Albumin Levels Among Hemodialysis Patients: A Community-Based Randomized Controlled Trial (pdf - 9 pgs)
In Control - Dialysis Patients' Need for Protein (pdf - 4pgs) Reprinted with permission from Life Options.
Barriers to Adequate Albumin Checklist (pdf - 2 pgs)
Albumin Facts (PDF - 1 pg)
kidneytools.com - This site requires users to go through a very short registration process before entering. Please go to "Nutrition A to Z" and be sure to see the "Nutrition Assessment" section. This contains the Subjective Global Assessment (SGA) as well as other assessment forms that can help determine a patient's nutrition status.

Albumin Magnets
Network #15 created albumin refrigerator magnets some time ago for distribution to dialysis patients. The magnet shows which foods are high in protein and how to measure the protein in these foods. Network #15 has no magnets left, however if you would like more (minimum order 50) you may purchase magnets directly from:

Karen Amack @ Images Everything
797 Shadowstone Drive
Highlands Ranch, Colorado 80129-1841

Phone: 303-683-9594
Fax: 303-683-7119

Large 3 1/2" x 6" magnet
Set of 50 $47.50
Shipping $5.15 per set

To copy the info from the magnet CLICK on the image to the right which can be downloaded for printing. arrow

click here to download protein magnet image

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National ESRD Elab Project

The ELAB collection is an annual process that attempts to collect and analyze data on 100% of the patients dialyzing in the US. This collection includes clinical data relating to anemia, adequacy of dialysis, nutrition, and mineral metabolism.  Following the collection, facilities receive a comparative trend report which can be used to evaluate their performance as it compares to their state and the Network. After each year’s collection, Network #15 and it’s Medical Review Board evaluate the information generated from the data in order to target facilities or geographical areas where there is an opportunity for clinical improvement. The Quality Improvement projects that have resulted have generated significant improvement in the care being provided in Network #15.

2010 Elab Report - (pdf - 100 pgs)

Previous year's reports may be found on the Network #11 Website

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Network #15 Adequacy/Access Project
The primary long-term goal of this project was and continues to be to increase and sustain the adequacy of hemodialysis (HD) in the Network #15 patient population.

Results of the Adequacy/Access Project:
Hemodialysis Adequacy and Catheter Use (PDF - 1 pg)
Adequacy by Access Type (PDF - 1 pg)
Prescribed vs. Delivered Dialysis, and Type & Location of Catheter (PDF - 1 pg)
Reasons for Long-term Catheters and Access Conversion Rates (PDF - 1 pg)
Final Report - Improving Hemodialysis Adequacy by Decreasing the Percent of Patients for Whom Vascular Access is a Long-term Catheter (PDF - 10 pgs)

Adequacy/Access Tools
Permanent Vascular Access Surveillance/Intervention Flowchart (PDF - 2 pgs)
Temporary Access Surveillance (PDF - 2 pgs)
Accesses in Your Facility Are in Trouble if . . . (PDF - 1 pg)
Access History Forms (PDF - 2 pgs)
Monthly Vascular Access Surveillance Record (PDF - 1 pg)
Vascular Access Referral Summary (PDF - 1 pg)

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Anemia Management

Anemia Management Tools
Management of Patients with Sub-11 Hemoglobin (Power Point Presentation)
Treating Anemia Fact Sheet (pdf) - from AAKP
QI Project Template for Increasing Hemoglobin Levels (pdf)
Anemia Root Cause Assessment (pdf)
Resources for Maintaining Hemoglobin (pdf)
NKF KDOQI Guidelines for Anemia - Clinical Practice Guideline and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease: 2007 Update of Hemoglobin Target
Managing Anemia When you are on Dialysis (pdf) from National Kidney Foundation
Anemia in Kidney Disease and Dialysis - (pdf) from National Kidney and Urologic Diseases Information Clearinghouse
Anemia Resources from The Renal Network, Inc. (Network 4) - Please note that these resources are for educational purposes only, Network #15 facilities are not participating in the Network 4 Anemia Managment Quality Initiative Project, so will not be asked to complete scans, etc.

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Forum of ESRD Networks - Medical Advisory Council Toolkits

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WebEx Recordings (Note: You may be required to allow ActiveX or Java to install in order to see these recordings)

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Fluid Management

Fluid Management Mini Movie (English) also available  (En Español)  - This 3-minute mini movie called, "Let's Talk About ...Fluids" is a short, high-impact message to help dialysis patients understand why it is so important to manage fluids. This production was created by the Medical Education Institute and Intermountain ESRD Network (Network #15).

Reduce Hospitalizations with Volume Management - This 45-minute WebEx recording reviews important aspects related to fluid management for the patient on hemodialysis.

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Dialysis Facility Reports (DFRs) and Performance Score Reports

Dialysis Facility Reports (DFRs) are made available each year online at dialysisreports.org. Informatinon about accessing, viewing, downloading, and commenting on the Dialysis Facility Reports, Quarterly Dialysis Facility Compare (QDFC) reports, and Quality Incentive Program (QIP) Performance Score Reports can all be found at dialysisreports.org.

Important dates for 2013

  • August 29, 5:00 pm EDT- Preview period concludes. No more comments can be accepted.

DFR Instructions

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Intermountain End-Stage Renal Disease Network, Inc.
165 S. Union Blvd., Suite 466, Lakewood, CO 80228
Phone: 303-831-8818     Fax: 303-860-8392
Toll free for patients only: 1-800-783-8818 or 1-888-777-0105

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Supported by Centers for Medicare and Medicaid Services (CMS) Contract HHSM-500-2013-NW015C. The content of this web site does not necessarily reflect the views or policies of CMS or the Department of Health and Human Services; nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Network #15 assumes full responsibility for the accuracy and completeness of this web site.