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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. Forum of ESRD Networks - Medical Advisory Council Toolkits
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| 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.
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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.
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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.
| Quality Incentive Program Resources |
| QIP (2013-2014) Final Rule Document [CMS–1577–F] - (pdf - 89 pgs) - Large File |
| QIP Performance Score Certificate FAQs for Payment Year 2012 - (pdf - 12 pgs) |
| PY 2014 ESRD QIP Measures (pdf - 3 pgs) |
| National Healthcare Safety Network Information (NHSN) - from Network #17 Website |
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.
- Windows Media File of Water Wise Presentation - (79 minutes) Note: this is a large file so will take time to download and view
- PDF file of Water Wise Presentation - 56 pgs
- Transcript of audio from Water Wise Project Presentation (pdf - 15 pgs)
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) |
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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Overview |
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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. |
| 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 |
| 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 |
| 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 |
| 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 |
Change
#8: Cannulation Training for AV Fistulas |
| 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 |
| 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. |
| 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). |
| VascularWeb - See the Society for Vascular Surgery's endorsement of the Fistula First project. |
| 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. |
| Network #15 Fistula First (FF) Reports |
| Instructions for Interpreting Facility-specific FF Reports (pdf - 1 pg) |
| Step-by Step Guide to Analyzing AVF Data (pdf - 2 pgs) |
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 |
Chronic Kidney Disease (CKD)
| CKD Resources |
| What Lab Professionals Should Know About Chronic Kidney Disease - Webex Recording (65 minutes) |
| Diabetes & High Blood Pressure Make the Kidney Connection |
| Diabetes & High Blood Pressure Make the Kidney Connection, What African Americans Need to Know |
| Diagnosis Codes and Billing for CKD (pdf - 1 pg) |
| Patient Self-Assessment for Kidney Disease (pdf - 1 pg) |
| Provider CKD Information Tool (pdf - 1 pg) |
| Screening for Occult Renal Disease (SCORED) (pdf - 8 pgs) |
| Explaining GFR - How Your Kidneys Work - Spanish Version |
| "Wait too long to talk about kidney disease and you could be waiting for a kidney" - Poster |
| You Have the Power to Prevent Kidney Disease: A health education video from NKDEP |
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.
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.
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 500) you may purchase magnets directly from:
Karen Amack @ Images Everything
797 Shadowstone Drive
Highlands Ranch, Colorado 80129-1841
Phone: 303-683-9594
Fax: 303-683-7119To copy the info from the magnet click on the image to the right which can be downloaded for printing.
Back to top
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
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)
| 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) |
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. |
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.
- Windows Media Video Version of QAPI Presentation - 64 minutes
- Online Survey - After viewing the above QAPI Presentation please take a moment to complete this short survey.
- 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.
- Windows Media Video Version of Water Wise Project Presentation (Windows Media Video)
- Transcript of audio from Water Wise Project Presentation (pdf - 15 pgs)
- 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.
- 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.
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.
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
For Network #15 Patients | For Network #15 Providers | About Network #15 | Contact Us
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.