Clinical indicator goals project
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Clinical Indicator Goals Project. Shean Strong, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 December 14, 2009. Clinical Indicator Goals Project . Background: Clinical Performance Measures (CPM) Project: Started in 1994 Random sampling of HD and PD patients

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Clinical indicator goals project

Clinical Indicator Goals Project

Shean Strong, QI Director

Lisle Mukai, QI Coordinator

ESRD Network 18

December 14, 2009


Clinical indicator goals project1

Clinical Indicator Goals Project

Background:

Clinical Performance Measures (CPM) Project:

  • Started in 1994

  • Random sampling of HD and PD patients

  • Collection of lab values

    • October – December (HD facilities)

    • October – March (PD facilities)


Clinical indicator goals project2

Clinical Indicator Goals Project

  • Laboratory values collected:

    • Hemoglobin

    • TSAT

    • Ferritin

    • URR

    • Kt/V

    • Albumin

    • Calcium

    • Phosphorus


Clinical indicator goals project3

Clinical Indicator Goals Project

Uses of data:

  • Provides comparative data for facilities

    • National and local benchmarks

  • Allows the Network to identify areas for improvement within patient care

  • Allows the Network to assess the standard practice of the community for specific clinical indicators

  • The basis for setting Network goals


  • Clinical indicator goals project4

    Clinical Indicator Goals Project

    Lab Data Collection (Elab) Project:

    • Started in 1998

    • Nearly 100% sampling of HD and PD patients

    • Collection of lab values for the last quarter of each year

    • Same lab values collected as CPM project


    Clinical indicator goals project5

    Clinical Indicator Goals Project

    Uses of data:

    • Facility-specific generated reports

    • Provides comparative data for facilities

      • National and Network

  • Allow facilities to identify area(s) for improvement within patient care

  • Allows the Network to identify facilities who need to improve outcomes in specific clinical indicators


  • Clinical indicator goals project6

    Clinical Indicator Goals Project

    Clinical Performance Goals-Network goals:

    • Goals are based on past performance, CMS thresholds and the NKF/KDOQI Clinical Practice Guidelines.

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


    Clinical indicator goals project7

    Clinical Indicator Goals Project

    • Expectation is that facilities not meeting expected performance standards be monitored by the Network and develop internal quality monitors to promote continuous improvement.


    Clinical indicator goals project8

    Clinical Indicator Goals Project

    2009-2010 Clinical Performance Goals:


    Clinical indicator goals project9

    Clinical Indicator Goals Project


    Clinical indicator goals project10

    Clinical Indicator Goals Project

    ** The goal was set by the MRB because PD patients lose albumin with the PD fluid.


    Clinical indicator goals project11

    Clinical Indicator Goals Project


    Clinical indicator goals project12

    Clinical Indicator Goals Project

    Quality Improvement Work Plan: (QIWP)

    • Requirement under the Network’s contract

    • Consists of 4 specific areas:

      • Vascular Access - Fistula First

      • Clinical Performance Measures

      • Network-specific quality improvement

      • Facility-specific quality improvement


    Clinical indicator goals project13

    Clinical Indicator Goals Project

    Clinical Indicator Goals Project:

    • Inclusion Criteria:

      • Facilities not meeting Network goals for anemia

        (4% of patients with Hgb < 10)

      • Patient census of > 50 patients (HD)

      • Patient census of > 20 patients (PD)

    • Exclusion Criteria:

      • Acute/transitional facilities

      • Patient census < 50 patients (HD)

      • Patient census < 20 patients (PD)

      • VHA facilities

      • Facilities participating in CROWNWeb Phase 2


    Clinical indicator goals project14

    Clinical Indicator Goals Project

    • Objective:

      • All facilities will be required to develop a QAPI (Quality Assessment and Performance Improvement) Plan utilizing the PDSA model to improve their sub-10 Hgb, implement those plans and monitor their progress.

    • Goal:

      Decrease the percentage of patients with a Hgb < 10 by at least 2 percentage points by April 2010.

    • Timeline:

      • October 2009 – April 2010


    Clinical indicator goals project15

    Clinical Indicator Goals Project

    • Due dates:

      • Run Charts (June–August 2009): due September 30, 2009:

      • QAPI: due January 15, 2010

      • Quarterly Run Charts:

        • Oct-Dec 2009 (to be distributed in January)

        • Jan-Mar 2010 (to be distributed in April)


    Clinical indicator goals project16

    Clinical Indicator Goals Project

    Network Responsibilities:

    • Project Leader

    • Instruct/assist with the QI process

    • Distribute templates for RCA and PDSA

    • Distribute resources and evaluate their usefulness

    • Provide technical assistance as necessary

    • Conduct facility site visits as necessary


    Clinical indicator goals project17

    Clinical Indicator Goals Project

    Facility Responsibility:

    • Conduct a root-cause analysis and develop a QAPI Plan

      • Submit a copy of the QAPI plan to the Network

  • Implement QAPI plan and revise as necessary during the project

  • Monitor facility’s progress towards achieving the goal

  • Follow project timelines/due dates

  • Submit requested documents for the project in a timely manner


  • Quality assessment and performance improvement plan qapi

    Quality Assessment and Performance Improvement Plan (QAPI)

    494.110: (V626) Condition

    The dialysis facility must 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.


    Quality assessment and performance improvement plan qapi1

    Quality Assessment and Performance Improvement Plan (QAPI)

    • Interdisciplinary Team: (minimum)

      • Physician

      • Registered nurse

      • Social Worker

      • Dietitian


    Quality assessment and performance improvement plan qapi continued

    Quality Assessment and Performance Improvement Plan (QAPI) (continued)

    Standard: Program Scope:

    1. The program must include, but not limited to, an ongoing program that achieves measurable improvement in healthcare outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.


    Quality assessment and performance improvement plan qapi continued1

    Quality Assessment and Performance Improvement Plan (QAPI) (continued)

    Standard: Program Scope:

    2. The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations.


    Quality assessment and performance improvement plan qapi continued2

    Quality Assessment and Performance Improvement Plan (QAPI)(continued)

    Standard: Monitoring performance improvement:

    The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.


    Quality improvement process

    Quality Improvement Process

    The process involves:

    • Defining the problem

    • Investigating through gathering evidence

    • Identifying root causes

    • Implementing solutions

    • Monitoring those solutions to ensure they

      continue to prevent the original problem.

    Rootcauseanalybasics.com


    Quality improvement process continued

    Quality Improvement Process (continued)

    Root Cause Analysis (RCA):

    At its most basic, the process asks three questions, which together provide the framework of a root cause analysis investigation:

    1. What was the problem?

    2. What were the causes of the problem?

    3. What actions should be taken to prevent the problem from occurring again?

    Rootcauseanalybasics.com


    Quality improvement process continued1

    Quality Improvement Process (continued)

    • Root cause analysis can use a variety of techniques to uncover root causes, including cause mapping, change analysis, the Ishikawa fishbone diagram, 5 Whys, and others.

    • All are designed to analyze the elements affecting a particular outcome to determine the root causes.

    Rootcauseanalybasics.com


    Quality improvement process continued2

    Quality Improvement Process (continued)

    Root Cause Analysis Investigations:

    • Every cause uncovered by RCA must be backed up by evidence.

    • RCA usually uncovers a system of root causes.

    • RCA uncovers specific causes and effects.

    • RCA results in executable, quantifiable solutions that may be monitored.

    Rootcauseanalybasics.com


    Quality improvement process continued3

    Quality Improvement Process (continued)

    Root Cause Analysis Investigations: (continued)

    • RCA does not point blame at any one person or group, but simply identifies a system of causes and effects that lead to and incident.

    • RCA focuses on past events.

    Rootcauseanalybasics.com


    Quality improvement process continued4

    Quality Improvement Process(continued)

    Fishbone Diagram

    (aka: Cause and Effect Diagram)

    • The fishbone diagram will help to visually display the many potential causes for a specific problem or effect.


    Quality improvement process continued5

    Quality Improvement Process (continued)

    Fishbone Diagram (continued)

    • The Cause-and-Effect diagram can be used by individuals or teams - most effective by a group.

    • The team assists by making suggestions of possible causes until no more causes can be suggested.

    • Once the entire fishbone is complete, a team discussion takes place to decide what are the most likely root causes of the problem.


    Quality improvement process continued6

    Quality Improvement Process (continued)

    Fishbone Diagram: (continued)

    • Benefits of a fishbone diagram:

      • It helps teams understand that there are many causes that contribute to an effect.

      • It graphically displays the relationship of the causes to the effect and to each other.

      • It helps to identify areas for improvement.

    Institute for Healthcare Improvement


    Quality improvement process continued7

    Quality Improvement Process (continued)

    5 Whys:

    Repeatedly asking the question “Why” to peel away the layers of symptoms which can lead to the root cause of a problem.

    • Although this technique is called "5 Whys," you may find that you will need to ask the question fewer or more times than five before you find the issue related to a problem.

    Six Sigma (www.isixsigma.com)


    Quality improvement process continued8

    Quality Improvement Process (continued)

    Benefits Of The 5 Whys

    • Help identify root cause of a problem.

    • Determine the relationship between different root causes of a problem.

    • One of the simplest tools; easy to complete without statistical analysis.

    Six Sigma (www.isixsigma.com)


    Quality improvement process continued9

    Quality Improvement Process (continued)

    Whys And The Fishbone Diagram

    • The 5 Whys can be used individually or as a part of the fishbone diagram.

    • The fishbone diagram helps you explore all potential or real causes that result in a single defect or failure.

    • Once all inputs are established on the fishbone, you can use the 5 Whys technique to drill down to the root causes.

    Six Sigma (www.isixsigma.com)


    Clinical indicator goals project

    Whys And The Fishbone Diagram

    Six Sigma (www.isixsigma.com)


    Quality improvement process continued10

    Quality Improvement Process: (continued)

    Plan-Do-Study-Act:

    PDSA is the format the Network uses for developing a QAPI plan.

    ACT

    PLAN

    STUDY

    DO


    Quality improvement process continued11

    Quality Improvement Process:(continued)

    • Quality improvement is a continuous cycle of planning, implementing strategies, evaluating the effectiveness of these strategies and reflection to see what further improvements can be made.

    Royal Children’s Hospital Melbourne – Clinical Quality & Safety


    Quality improvement process continued12

    Quality Improvement Process:(continued)

    • PDSA approaches promote action by getting clinicians to reflect and brainstorm strategies that they hope will lead to improvement.

    • It also promotes evaluation of these changes once the strategies have been implemented.

    Royal Children’s Hospital Melbourne – Clinical Quality & Safety


    Quality improvement process continued13

    Quality Improvement Process:(continued)

    • PDSA is a cycle of improvement that involves asking three key questions:

      1. What are we trying to accomplish?

      2. How will we know that a change is an

      improvement?

      3. What changes can we make that will result

      in an improvement?

    NHS Scotland (www.clinicalgovernance.scot.nhs.uk


    Clinical indicator goals project

    PDSA Template


    Quality improvement process continued14

    Quality Improvement Process:(continued)

    • Plan:

      • Set your objective for the project

      • Set goals to achieve (numerical goals and

        a target date)

      • Develop your plan on how you will

        improve your identified problem

      • Include a plan for collecting data

      • List data sources you will use to monitor

        your progress for the project


    Quality improvement process continued15

    Quality Improvement Process:(continued)

    Plan (continued):

    • Write out the measure you will be using

      to analyze if you are achieving your

      goal. (numerical formula)

      Example:

      # of prevalent patients using AVF as primary access = AVF rate

      Total # of patients at the facility


    Quality improvement process continued16

    Quality Improvement Process:(continued)

    Plan (continued):

    • Note the frequency in which you

      will conduct measurement of your

      progress

    • Note your baseline for comparison

      towards your goal


    Quality improvement process continued17

    Quality Improvement Process:(continued)

    Do:

    • Implement your plan

    • Document problems and unexpected

      observations of your plan

      Study:

    • Analyze the results and compare it to the goal

    • This analysis should be conducted with the

      interdisciplinary team.


    Quality improvement process continued18

    Quality Improvement Process:(continued)

    Act:

    • Is your plan successful?

    • How will you ensure continued

      improvement?

    • If it wasn’t successful, what needs to be

      changed based on what you have learned?

    • Should you continue to search for other

      root causes?


    Plan do study act pdsa continued

    Plan-Do-Study-Act (PDSA) (continued)

    • The PDSA cycle is a continuous cycle. It allows you to frequently assess your plan and make revisions as necessary to achieve your goal.

    • Your plan should be reviewed at least monthly and/or when you realize that your strategy or activity is not working.


    Quality improvement process continued19

    Quality Improvement Process:(continued)

    • Note your progress on your form so that you have a record of the strategies/activities you’ve attempted and results of those attempts as well as the revisions you have made to improve your plan.


    Conditions for coverage anemia management

    Conditions for Coverage:Anemia Management

    The ESRD Conditions for Coverage include anemia as one of the clinical indicators required to be addressed in both the patient assessment and the facility’s QAPI program.

    FMQAI – Network 7


    Conditions for coverage anemia management1

    Conditions for Coverage:Anemia Management

    V405:

    Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s).

    V632:

    Anemia management.


    Factors that contribute to anemia or lead to esa hypo responsiveness

    Factors that contribute to anemia or lead to ESA hypo-responsiveness:

    • Inadequate EPO dose

    • Iron deficiency (True or Functional)

    • Blood loss

    • Infection or inflammation

    • Aluminum toxicity

    FMQAI-Network 7


    Factors that contribute to anemia or lead to esa hypo responsiveness continued

    Factors that contribute to anemia or lead to ESA hypo-responsiveness: (continued)

    • Secondary Hyperparathyroidism

    • Co-existing medical conditions

    • Hemolysis

    • Malnutrition

    • Vitamin deficiency (B12, Folic Acid, B6)

    FMQAI-Network 7


    Factors that contribute to anemia or lead to esa hypo responsiveness continued1

    Factors that contribute to anemia or lead to ESA hypo-responsiveness: (continued)

    • Evaluation for hypo-response is indicated when patient response to EPO administration is not observed.

    • Once identified the underlying cause can be addressed

    • When the cause is resolved, ESA dose can be adjusted to prevent from exceeding recommended range.

    FMQAI-Network 7


    Clinical indicator goals project

    Document from Amgen


    Anemia management lab values

    Anemia Management: Lab Values

    Laboratory Monitoring for Anemia:

    • Hemoglobin and Hematocrit

    • Transferrin Saturation (Tsat)

    • Ferritin

    • Reticulocyte hemoglobin content (CHr)


    Summary

    Summary:

    • Facility to conduct a root-cause analysis of why your patients have a Hgb of < 10.

    • Develop a Quality Assessment Performance Improvement (QAPI) Plan to decrease the percentage of patients with a sub-10 hemoglobin.

      • QAPI must be signed by the Medical Director

      • Submit a copy to the Network by January 15, 2010.

        • ONLY STEP 1 (PLAN) is due

          on January 15th.


    Summary1

    Summary:

    • Implement and monitor progress of your QAPI plan.

    • The Network will distribute quarterly run charts to monitor progress.


    Project communication

    Project Communication:

    • To communicate more efficiently with you about this project and to be more eco-friendly, we are creating a listserv of all the facilities in this project.

    • In the past, we have had e-mail delivery problems with facility firewalls, please ensure you are able to receive e-mails from us about the project.

      • Consult with your IT Department to

        assist you.


    Clinical indicator goals project

    Shean Strong, MBA, QI Director

    [email protected]

    Lisle Mukai, RN, QI Coordinator

    [email protected]

    ESRD Network 18

    323-962-2020

    Network 18 website: www.esrdnetwork18.org


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