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Quality Improvement

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

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


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

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Quality Assessment and Performance Improvement (QAPI)

The Conditions for Coverage for ESRD Facilities contains a requirement for facilities to develop and maintain a QAPI program. The program must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. Specific areas of focus include:

  • adequacy of dialysis
  • nutritional status
  • mineral metabolism renal bone disease
  • anemia management
  • vascular access
  • medical injuries and medical error identification
  • reuse of dialyzers
  • patient satisfaction
  • 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)

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

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PD Adequacy

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. 

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.

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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

Web site Links
Network #15 Reports


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.
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 (pdf)

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
Autologous AV Fistula Algorithm
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
Sleeves Up Protocol

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
Physician Letter to Catheter Patient

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
Self-Cannulation of Fistulas Patient Policy and Procedure
Self-Cannulation of Fistulas Staff Policy and Procedure
Training Checklist for Self-Cannulation

Change #9: Monitoring and Maintenance to Ensure Adequate Access Function
Bruit Audio Clips - from the 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
Vascular Access Referral Intervention Log
Vamp© Vascular Access Monitoring & Surveillance Flow Chart

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
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. - 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)

Tools for Increasing Arteriovenous Fistulas
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.
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)

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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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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.

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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Improving 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
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) - 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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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.

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)
Anemia Root Cause Assessment (pdf)
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

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Forum of ESRD Networks - Medical Advisory Council Toolkits

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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).

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Dialysis Facility Reports (DFRs) and Performance Score Certificates

Dialysis Facility Reports (DFR's) are moving!! They will no longer be available at Instead, beginning November 1, 2014, both the quarterly and annual Dialysis Facility Reports will be housed at a new Dialysis Data website: . Passwords and accounts for the old location will NOT WORK on the new website.

Instructions for setting up user accounts for accessing

Performance Score Certificates from 2014 (which represent 2013 data) will be available on the website ONLY until January 15, 2015. After that date the website will cease to operate. CMS has not announced where the PSCs will be housed in the future.


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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.