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.
Forum of ESRD Networks - Medical Advisory Council Toolkits
following documents can be used as guidelines for deciding on and
implementing Quality Improvement Projects.
(pdf - 4 pgs)
QI Project Examples, Root Cause Assessments, and Resources:
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 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 Coordinator, Tamyra Warmack, RN and Quality Improvement Director, Karen Strott, BSN, RN, designed to increase facility staff's knowledge of the QAPI process. 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.
CMS Quality Incentive Program
In 2011 the Centers for Medicare & Medicaid Services (CMS) completed implementation of the first year of the ESRD Quality Incentive Program (QIP) designed to encourage the delivery of high-quality services in dialysis facilities. The ESRD QIP is one of several pay-for-performance or “value-based purchasing” initiatives that CMS has undertaken to transform the healthcare payment system to one that considers the quality of services provided to beneficiaries, not just the quantity of services provided. The final rule for the 2013-2014 appears below, as well as resources related to the 2012 and 2013-2014 payment periods.
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.
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.
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
Fistula First - NVAA Project
Web site Links
Network #15 Reports
NVAII is the acronym for the National Vascular Access Improvement
Initiative and is a nationwide campaign to increase the use
of arterial venous fistulas (AVF). This project, also known as the
"Fistula First" initiative, was launched July 1, 2003
by CMS. The
Fistula First mission is to make sure that every eligible ESRD patient
receives his/her optimal form of vascular access (in the majority
of cases AVF) and to avoid vascular access complications through
appropriate monitoring and intervention. Network
#15's strategy includes a variety of activities that target the
different needs of varied audiences. We will emphasize improved
communication between the nephrologist, the vascular surgeon, the
interventional radiologist, and dialysis staff.
with Fistula First Resources
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.
|Patient Education Resource Evaluation - Click here to take an online questionnaire about your use of the resources contained in the Patient Education Resources Notebook (see above link).
- See the Society for Vascular Surgery's endorsement of the Fistula
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.
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.
features of this project included:
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.
educational events with nephrologists, surgeons, and nurse educators
to present different perspectives on fistula placement.
"Change Packets" that contain resource materials for
surgeons, nephrologists, facility staff, and patients.
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).
Chronic Kidney Disease (CKD)
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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 its 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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Quality Initiative - Improving Albumin Levels
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!
below (previously mailed to all facilities) may be helpful
in achieving higher albumin levels:
#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:
Amack @ Images Everything
797 Shadowstone Drive
Highlands Ranch, Colorado 80129-1841
copy the info from the magnet click on the image to the
right which can be downloaded for printing.
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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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#15 Adequacy/Access Project
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.
#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.
began in January 2001. The final data collection occurred in January
2002 and the final report was approved by CMS in October 2002.
of the Adequacy/Access Project:
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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WebEx Recordings (Note: You may be required to allow ActiveX or Java to install in order to see these recordings)
- Quality Assessment and Performance Improvement (QAPI) – (Webex Recording file - 64 minutes) - A presentation by Network #15’s Quality improvement Coordinator, Tamyra Warmack, RN and Quality Improvement Director, Karen Strott, BSN, RN, designed to increase facility staff's knowledge of the QAPI process.
- 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.
- Dialysis Reimbursement: Patient Care and Economics (60 minutes) - presented by the Network #15 QI Dept
- Updated Conditions for Coverage presented by Network #15
- What Lab Professionals Should Know About Chronic Kidney Disease (65 minutes) - presented by Andrew S. Narva, MD.
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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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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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
For Network #15 Patients
Network #15 Providers |
About Network #15
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.