One of the primary objectives of ESRD Networks is to improve the quality of health care services for ESRD patients. Methods used to accomplish this goal include Quality Improvement Projects. Network #15 is involved in both national QI Projects and in Network-defined QI Projects.

MAC Toolkits

• Catheter Reduction Toolkit
• Diabetes Care Coordination Toolkit
• Medical Reconciliation Toolkit
• Vaccination Toolkit

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:

• Decreasing Central Venous Catheters / Increasing AVFs (pdf - 8 pgs)
• Increasing Albumin Levels (pdf - 4 pgs)
• Improving Immunization Rates (pdf - 5 pgs)
• Increasing Home Dialysis Options (pdf - 8 pgs)
• Decreasing Infection in Peritoneal or Hemodialysis Patients (pdf - 5 pgs)

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Resources for Achieving Fistula First Goals

Project Overview (pdf)

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.

Example QI Project for Decreasing Central Venous Catheters / Increasing AVFs

Patient Education Resource Evaluation - Click here to take an online questionnaire about your use of the resources contained in the Patient Education Resources Notebook.

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 • KDOQI Summary Guidelines - Management of Complications: When to Intervene (pdf) • Hemodialysis Access Referral Form: New Access (pdf)

Change #4: Surgeon Selection Based on Best Outcomes, Willingness, and Ability to Provide Access Services • KDOQI Summary Guidelines - Patient Evaluation Prior to Access Placement (pdf) • Surgeon Questionnaire (pdf) • Universal Vascular Access Diagram (pdf)

Change #5: Full Range of Appropriate Surgical Approaches to AVF Evaluation and Placement • "Creating AV Fistulas in all Eligible Hemodialysis Patients" - Continuing Medical Education presentation showing the fundamentals of placing AV Fistulas and surgical strategies for successful 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 • Order Form for Medisystems Cannulation Video (pdf) • Ordering Info for Dr. Twardowski's Buttonhole Method Video (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) • Clamp Usage Policy and Procedure (pdf) • Have More Control Over Your Dialysis and Health • FAQ about Arterial Venous Fistula's (AVF) • Fistula Preservation, Development, and Maintenance (pdf) • Patient Resources List (pdf) • Related Articles for Vascular Access (pdf) • Staff Resources (pdf)

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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)

Executive Summary (PDF - 2 pgs)

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.

Chart for Identifying Root Causes of Low AVF Rates (PDF - 1 pg)

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)

Final Report on Increasing AVF Within Network #15 (PDF - 10 pgs)

Example QI Project for Decreasing Central Venous Catheters / Increasing AVFs

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Chronic Kidney Disease (CKD)

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Safe and Timely Immunization Coalition (STIC)
A national coalition comprised of healthcare professionals and patients with End Stage Renal Disease was formed in 2005 at the request of CMS to increase the rate of Hepatitis B, Influenza, and Pneumococcal immunizations in patients and staff in the dialysis setting. The following educational resources can be used to help achieve this goal.

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MIMI (Multiple Immunization Monitoring Instrument)

MIMI is an Excel-based tracking tool designed to assist dialysis clinics with monitoring vaccination information and in getting all needed vaccinations provided in a timely way. MIMI will let you quickly see each patient’s current vaccination status, and can generate lists of patients needing a given vaccination. With chart generation to show you your overall rates, tracking of “refused” vaccinations, monitoring of “no information available” patients, and even an automatic reporting feature (for future STIC collections performed by the Network), MIMI will help address your vaccination tracking needs in one easy-to-learn and use interface.

MIMI Instructions - (pdf) - (Please read these BEFORE dowloading MIMI) - A guide that will help you to download MIMI and to learn all of MIMI’s features. While every attempt has been made to make MIMI intuitive to learn and use, these instructions will assure that you get full use of MIMI’s tracking and monitoring.

Download MIMI Here (MS Excel) - System requirements: Windows computers only! Must be running Excel 5.0 or later – and security settings must be such that the operation of macros is allowed. (See instructions above.)

Bug report FaxBack (pdf) - Network #15 is always looking for ways to better support the ongoing QI efforts our clinics are making, and we hope that MIMI – and perhaps other tools like it – will make these QI tasks easier to complete effectively. Your feedback about this tool and the sort of experience you had using MIMI will help us refine and enhance the tool for future versions. We encourage you to report any difficulties you may experience using this resource (as well as any positive experiences, or your general feedback) to Network #15 using the one-page feedback form available at this link.

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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:

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 500) 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 To copy the info from the magnet click on the image to the right which can be downloaded for printing.

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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.

2008 Elab Report - (pdf - 99 pgs)

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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.

The Network #15 goal is to have at least 80% of adult in-center HD patients achieve a delivered dose of dialysis (65% as measured by the Urea Reduction Ratio). As a group, Network #15 facilities continue to achieve this goal. However, in both preliminary and follow-up data, patients with catheters showed a higher likelihood of not receiving adequate dialysis. For this reason, Network #15 facilities are encouraged to focus on improving adequacy for this sub-group of patients. Facilities should strive to achieve the goal of having less than 10% of patients maintained on catheters as their permanent access. For those patients who must continue to have a catheter as their primary access KDOQI recommends URRs of > 65% and Kt/Vs of > 1.2.

This project began in January 2001. The final data collection occurred in January 2002 and the final report was approved by CMS in October 2002.

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)

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Infection Control

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Anemia Management

Anemia contributes to a persistent poor quality of life if left untreated in ESRD patients. The CMS/K/DOQI targets for anemia management are to attain/maintain a Hgb of >11gm/dL for at least 70% of all patients. However, the Network #15 Medical Review Board has set a stretch goal of attaining/maintaining these levels for 85% of all patients. The following Power Point Presentation covering anemia management was given in December of 2006 - Management of Patients with Sub-11 Hemoglobin.

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WebEx Recordings

• Webex on Updated Conditions for Coverage presented by Network #15
  • Day 1 - Patient Safety
  • Day 2 - Patient Care Part I
  • Day 3 - Patient Care Part II
• What Lab Professionals Should Know About Chronic Kidney Disease (65 minutes) - presented by Andrew S. Narva, MD.
• Introduction to Fault Tree Analysis (50 minutes) - Fault tree analysis is a QI tool that can be used to help identify and evaluate the potential weaknesses in your healthcare system which might be contributing to poor patient outcomes.

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KECC/Dialysis Facility Reports

Guide to the 2009 Dialysis Facility Reports - This guide explains in detail the contents of the Dialysis Facility Reports (DFRs) that were
prepared by the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) for each dialysis facility. Facility-specific DFRs were mailed to the Medical Directors and Clinical Managers within NW #15 in July of 2009.

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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-500-2006-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.