Clinical Indicator Goals:  Are You on Target?
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Clinical Indicator Goals: Are You on Target?. Svetlana (Lana) Kacherova, QI Director July 30 & 31, 2008. Health Care Quality Improvement Program (HCQIP). The Center for Medicare & Medicaid Services (CMS) contracts with 18 ESRD Network Organizations throughout the United States

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Clinical Indicator Goals: Are You on Target?

Svetlana (Lana) Kacherova, QI Director

July 30 & 31, 2008


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Health Care Quality Improvement Program (HCQIP)

  • The Center for Medicare & Medicaid Services (CMS) contracts with 18 ESRD Network Organizations throughout the United States

  • The ESRD Networks perform oversight activities to assure appropriateness of services and protection for ESRD patients.

  • This approach has been named the ESRD Health Care Quality Improvement Program (HCQIP)



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ESRD Network National Goals

  • Improve the quality of health services & quality of life for ESRD beneficiaries

  • Improve data reporting, reliability, & validity between providers, NWs, and CMS

  • Evaluate and resolve patient grievances

  • Support the marketing, deployment, and maintenance of CMS approved software

    CMS, ESRD NW Organization Manual


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ESRD Network National Goals

  • Establish & improve partnerships & cooperate activities with

    • Providers & Owners

    • NWs, Quality Improvement Organizations (QIOs)

    • State Survey Agencies

    • Professional Groups & Patient Organizations

      CMS, ESRD NW Organization Manual


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Network 18 Mission Statement

To provide leadership and assistance to renal dialysis and transplant facilities in a manner that supports continuous improvement in patient care, outcomes, safety and satisfaction.


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Network 18 Definition of Quality

“Doing the right thing correctly

the first time.”


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Patients In Our Network(2006/2007 Annual Report)

  • How Many?

    • Incident – 8,428 / 6,819

    • Prevalent – 27,600 / 29,131

    • Deaths – 5,369 / 5,432



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Delivering Care to Dialysis Patients

  • Dialysis Facilities – (n=305)

    • Ownership

      • Large Corporate (LDO) - 157

      • Non-Corporate (Independent) - 148

    • Location

      • Freestanding

      • Hospital


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Goals Established by the ESRD Network based on:

  • Past performance

  • CMS thresholds

  • NKF/KDOQI Clinical Practice Guidelines

  • The expectation is that facilities not meeting expected performance standards will develop internal quality monitors to promote continuous improvement


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Clinical Performance Goals

  • Provides measurement tool to assess facility patient care processes and outcomes, and identify opportunities for improvement.

  • The Network goal is to combine efforts with renal facilities to improve performance in the delivery of quality patient care


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ESRD Clinical Performance Measures (CPM) Project:

  • National effort led by CMS and 18 ESRD Networks that started in 1994

  • Random sample of patients that are representative of each Network

  • For HD patients – (October-December 2006)

  • For PD patients – (October 2006- March 2007)


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Five Major Domains of Care:

  • Adequacy of Dialysis

  • Anemia Management

  • Nutritional Status

  • Bone and Mineral Metabolism

  • Vascular Access


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Adequacy of Dialysis

  • Numerous outcome studies have demonstrated a correlation between the delivered dose of hemodialysis and patient mortality and morbidity

  • Pre and post-dialysis blood urea nitrogen (BUN) levels were drawn and reported to calculate URR results

  • Kt/V was calculated using the pre- and post BUN, post dialysis weight, and time on dialysis


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Adequacy of Dialysis: adult HD pts (URR)

The Network’s goal is to achieve 88% of patients with a URR ≥ 65%


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Adequacy of Dialysis Adult HD pts (Kt/V)

The Network’s goal is to have 88% of patients with a Kt/V ≥ 1.2.


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2007 Annual Report: Opportunities to Improve Adequacy

  • 10% of patients did not have a mean Kt/V > 1.2 during the three-month study period



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2007 CPM Results Pediatric HD Patients: Adequacy Dialysis

Opportunities to improve Clearance:

10% of patients did not have a mean sp Kt/V > 1.2 during the three-month study period


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2007 CPM Results Pediatric PD Patients: Clearance Dialysis

Opportunities to improve Clearance:

13% of patients did not have a mean weekly Kt/V > 1.8 during the six-month study period




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Anemia Management Adult HD pts (Hgb) Dialysis

The Network’s goal is to maintain 85% of patients with Hgb > 11.0



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2007 Annual Report: Opportunities to Improve Anemia Management

  • 16% of patients did not have a mean HGB > 11.0 (g/dl) during the three-month study period

  • 21% of patients did not have a mean TSAT > 20% and 5% of patients did not have a mean Serum Ferritin > 100 ng/ml


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2007 CPM Results Pediatric HD Patients: Anemia Management Management

Opportunities to improve Anemia:

31% of patients did not have a mean Hgb > 11.0 g/dl during the three-month study period


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2007 CPM Results Pediatric PD Patients: Anemia Management Management

Opportunities to improve Anemia:

29% of patients did not have a mean Hgb > 11.0 g/dl during the six-month study period



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Iron Studies LDC 2007


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Nutritional Status Adult HD patients LDC 2007

The Network’s Goal for dialysis units is to maintain 84% of patients with

a mean serum albumin ≥ 3.5/3.2 gm/dL (BCG/BCP).


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2007 Annual Report: Opportunities to Improve Serum Albumin LDC 2007

  • 66% of patients did not have a mean serum albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period

  • 19% of patients did not have a mean serum albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period


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2007 CPM results U.S. Adult PD patients: LDC 2007Serum Albumin

Opportunities to improve Serum Albumin:

81% of patients did not have a mean Serum Albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period

37% of pts did not have a mean Serum Albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period


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2007 CPM Results Pediatric HD Patients: Serum Albumin LDC 2007

Opportunities to improve Serum Albumin:

51% of patients did not have a mean Serum Albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period

18% of pts did not have a mean Serum Albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period








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2007 Annual Report: Opportunities to Improve Vascular Access – LDC 2007

  • 58% of incident patients and 55% of all patients were not dialyzed with an AVF during their last hemodialysis session Oct-Dec 2006

  • 32% of patients with an AVF or AVG did not have their access routinely monitored for the presence of stenosis during the three month study period



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What is the most visible QI project in Network 18? 1995-2006

  • Fistula First (Fistula First Breakthrough Initiative)


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“Fistula First” GOAL 1995-2006

Goal is to maximize autogenous AVF construction & success rate…..

To achieve in the shorter term (2006) the initial K/DOQI minimum benchmark of AVF use in 40% of prevalent patients….

And in the long-term (2009), a 66% AVF rate in prevalent patients

Additional Goal: Reduce Catheter Use!


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Improvement in Prevalent 1995-2006AVF Rates by ESRD Network

FFBI AVF goal 66%


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Fistula First Goals (AVF Rates) 1995-2006

  • CMS goal – 66% by June 30, 2009

  • Yearly Network 18 goal – 55.1 % by June 30, 2009

  • Yearly Network Stretch Goal – 56.0% by June 30, 2009

  • May 2008 AVF rates: NW 18 – 53.0%

    US – 49.7%


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Routine CQI Review of vascular access 1995-2006

Timely referral to nephrologist

Early referral to surgeon for “AVF Only”

Surgeon Selection

Full range of appropriate surgical approaches

Secondary AVFs in AFG patients

AVF evaluation/placement in catheter pts

Cannulation training

Monitoring and maintenance

Continuing Education

Outcomes feedback

Tools & Best Practices:Fistula First Change Concepts


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New Conditions for Coverage: QAPI (Quality Assessment and Performance Improvement)

  • Condition Level

  • Interdisciplinary Team

  • Process continuous and on-going

  • Outcome focused: use community accepted standards and targets

  • Include patient satisfaction, infection control, medical injuries and medication errors

  • Plan/Do/Check/Act: Close the loop!


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PDCA Style Performance Improvement)

ACT

PLAN

CHECK

DO


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QAPI Program requirements Performance Improvement)

  • Action-oriented

  • Data-driven

  • Under the direction of Medical Director

  • Requires RN and interdisciplinary team participation

  • Quality Improvement Committee


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Quality Improvement Activities Performance Improvement)

with Providers

  • CMS-approved QIPs (Fistula First)

  • Clinical Performance Measures Project (CPM)

  • Annual Lab Data Collection Project

  • Network-Specific Projects

  • Facility Specific QI Projects

  • Technical Assistance

  • Internal QI Program


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CMS-Approved QIPs Performance Improvement)

  • Anemia Management

  • Hepatitis B Vaccination

  • AV Fistula Placement

  • Hemodialysis Adequacy

  • Stenosis Monitoring (100%)

  • Fistula First


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Svetlana (Lana) Kacherova Performance Improvement)

Quality Improvement Director

[email protected]

6255 Sunset Boulevard • Suite 2211 • Los Angeles • CA • 90028

(323) 962-2020 • (323) 962-2891/Fax • www.esrdnetwork18.org


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