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Reduction in Long-Term Catheter Rate Project

Reduction in Long-Term Catheter Rate Project. Lisle Mukai , QI Coordinator ESRD Network 18 October 1, 2009. Special Acknowledgement for Slide Content Contribution:. Fistula First Breakthrough Initiative Website Mid-Atlantic Renal Coalition (FFBI: Presentation to CMS/ESRD-Annual Meeting)

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Reduction in Long-Term Catheter Rate Project

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  1. Reduction in Long-Term Catheter Rate Project Lisle Mukai, QI Coordinator ESRD Network 18 October 1, 2009

  2. Special Acknowledgement for Slide Content Contribution: • Fistula First Breakthrough Initiative Website • Mid-Atlantic Renal Coalition (FFBI: Presentation to CMS/ESRD-Annual Meeting) • CMS Surveyor Training (Condition: Quality Assessment and Performance Improvement - Show Me The Progress

  3. Fistula First Breakthrough Initiative (FFBI) • The FFBI is a collaboration between the Centers for Medicare and Medicaid Services (CMS), ESRD Networks, and the renal community. • Began in 2003 • Main objective: • To have every eligible patient receive the most optimal form of vascular access-AVF • To ensure every vascular access undergo appropriate monitoring and surveillance to avoid vascular access complications.

  4. Fistula First AVF Goals • CMS Prevalent AVF Goal = 66% Network 18 2009-2010 AVF Goal: • Network 18 Goal = 57.8% • Network 18 Stretch Goal = 58% Current AVF Rates: • National: 53.2% (July 2009) • Network 18: 56.9% (July 2009)

  5. CMS & Network 18 Goals for Long-Term Catheters CMS & Network 18 Long-Term Catheter (LTC) [> 90 Days] Goal = < 10% Current LTC Rate: • National: 21% (2008 CPM) • Network 18: 7.9% (July 2009 – SIMS data)

  6. Tools & Best Practices:Fistula First Change Concepts • Routine CQI Review of vascular access • Timely referral to nephrologist • Early referral to surgeon for “AVF Only” • Surgeon Selection • Full range of appropriate surgical approaches • Secondary AVFs in AVGpatients • AVF evaluation/ placement in catheter pts • Cannulation training • Monitoring and maintenance • Continuing Education • Outcomes feedback

  7. Cost Per Patient by Access Type(USRDS 2006 data) Annual Per Patient Per Year Expenditure • Catheter $77,093 • Graft $71,616 • AVF $59,470 The annual per patient cost savings of an AVF over a graft is $12,269 The annual per patient cost savings of an AVF over a catheter is $17,746

  8. Network 18 activities to promote & support Fistula First • Monthly data collection • Electronically by LDOs (DaVita & FMC) • Manual submission by Independent & SDOs. • Distribute quarterly feedback reports (Facility-specific reports, SIMS reports, and Network summary reports) • Sharing best practices via Fistula First Newsletter

  9. Network 18 activities to promote & support Fistula First (continued) • Provide current educational information relevant to professionals and patients on the NW 18 website and mailings. • Work with the MRB to develop projects to assist identified facilities in improving outcomes. • Site visits

  10. Reduction in Long-Term Catheter Rate Project • Facilities > 50% AVF Rate = 73.1% (198 facilities – as of May 2009) 108 facilities = 50-59% 67 facilities = 60-69% 23 facilities = > 70% • Facilities < 50% AVF Rate = 26.9% (73 facilities – as of May 2009)

  11. Reduction in Long-Term Catheter Rate Project (continued) • Facilities < 10% LTC Rate = 70.5% (191 Facilities – as of May 2009) • Facilities > 10% LTC Rate = 29.5% (80 Facilities – as of May 2009) 64 facilities = 10-19% 12 facilities = 20-29 % 3 facilities = 30-39% 1 facility = > 40%

  12. Reduction in Long-Term Catheter Rate Project (continued) Inclusion Criteria for the project: • LTC rate > 10% (May 2009 SIMS data) • AVF rate < 50% (May 2009 SIMS data) • Patient census > 50 patients Exclusion Criteria: • Patient census < 50 patients • Facilities already included in another QIWP Project (exception of SMR and Clinical Indicator Goals Project) • Facilities participating in Phase 2 of CROWNWeb

  13. Reduction in Long-Term Catheter Rate Project (continued) • Objective: • To have each participating facility review their vascular access program and determine root cause(s) for their facility’s increased LTC rate. • Each facility will develop a Quality Assessment and Performance Improvement Plan to improve their LTC rate based on their root cause analysis • Implement their plan and improve their plan along the way by making necessary changes if certain strategies/activities are not successful. • Develop a process to sustain improvements.

  14. Reduction in Long-Term Catheter Rate Project (continued) • Goal: Group Goal: To reduce the LTC rate within the group of intervention facilities from 16.6% to 15.6% by June 2010. Facility Goal: To reduce the facility’s LTC rate by at least 6% by June 2010. • Timeline: Project period: September 2009 to June 2010

  15. Reduction in Long-Term Catheter Rate Project (continued) • Due dates: • Facility Manager Acknowledgement Letter – August 27, 2009 • Environmental Scan – August 27, 2009 • Medical Director Acknowledgement Letter – September 10, 2009 • Quality Assessment and Performance Improvement Plan (PDSA: Plan-Do-Study-Act format) – November 4, 2009

  16. Reduction in Long-Term Catheter Rate Project (continued) • Conference Calls Monthly calls to share and discuss successes and issues. • Very important because it gives each facility the chance to discuss their concerns or share their issues with others and possibly find solutions to problems. • The 1st Wednesdays of the month starting on November 4, 2009 at 2pm.

  17. Reduction in Long-Term Catheter Rate Project (continued) • Network Responsibilities: • Project Leader • Instruct/assist with the QI process • Distribute templates for RCA and PDSA • Distribute toolkits/resources and evaluate their usefulness

  18. Reduction in Long-Term Catheter Rate Project (continued) Network Responsibilities (continued) • Provide monthly feedback reports (SIMS) • Facilitate monthly conference calls • Provide technical assistance as necessary • Conduct facility site visits as necessary

  19. Reduction in Long-Term Catheter Rate Project (continued) Facility Responsibility: • Conduct a root-cause analysis and develop a Quality Assessment and Performance Improvement (QAPI) Plan • Submit your QAPI plan • Implement QAPI plan and revise as necessary during the project • Monitor your facility’s progress towards achieving the goal

  20. Reduction in Long-Term Catheter Rate Project (continued) Facility Responsibility (continued): • Identify tools that would be useful for your facility • Participate in monthly conference calls • Follow project timelines/due dates • Submitting requested documents for the project in a timely manner

  21. 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.

  22. Quality Assessment and Performance Improvement Plan (QAPI) • Interdisciplinary Team: (minimum) • Physician • Registered nurse • Social Worker • Dietitian • Also include your surgeon(s) and interventional radiologist(s)

  23. 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.

  24. 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.

  25. 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.

  26. Quality Improvement Process Root Cause Analysis: Finding the real cause of the problem and dealing with it rather than simply dealing with the symptoms. • Those situations which are recurring with the greatest frequency and consume the greatest amount of resources to rectify are candidates for RCA • To find the root cause, ask “Why?” until the pattern completes and the cause of the difficulty in the situation becomes rather obvious. Gene Bellinger 2004

  27. Quality Improvement Process: Plan-Do-Study-Act: PDSA is the format the Network uses for developing a QAPI plan. ACT PLAN STUDY DO

  28. PDSA Template

  29. Plan-Do-Study-Act (PDSA) • 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 • List data sources you will use to monitor your progress for the project

  30. Plan-Do-Study-Act (PDSA) (continued) Plan (continued): • Write out the measure you will be using to analyze if you are achieving your goal. (numerical formula) # of prevalent patients using an LTC as primary access Total # of patients at the facility

  31. Plan-Do-Study-Act (PDSA) (continued) Plan (continued): • Note your baseline for comparison towards your goal • Note the frequency in which you will conduct measurement of your progress

  32. Plan-Do-Study-Act (PDSA) (continued) Plan (continued): In your plan, please include a process to monitor newly placed AV fistulas for maturation. • Ensure that the access is access using the Look, LISTEN, and Feel method. • Refer the patient for follow-up 4 weeks post placement to ensure the access is maturing properly.

  33. Plan-Do-Study-Act (PDSA) (continued) Plan (continued): When you develop your plan, write out your methodology (what you are going to do step-by-step). This way when you implement your plan you can go back to the step that may not have worked and revise it.

  34. Plan-Do-Study-Act (PDSA) (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. • Revise plan if necessary to achieve goal

  35. Plan-Do-Study-Act (PDSA) (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?

  36. 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.

  37. Plan-Do-Study-Act (PDSA) (continued) • You can go back to any step and revise as necessary. • 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.

  38. Overcoming Obstacles and Barriers Categories for Network 18 facilities’ common obstacles and barriers: • Education • Process • Communication

  39. Overcoming Obstacles and Barriers (continued) Insurance: Communication: • When you send a patient to the surgeon for de-clotting of an AVG or catheter send a letter to that surgeon explaining all the difficulties and frequency of those difficulties you have had with that access and why you would like that patient evaluated for an AVF. When the problem occurs frequently, it is justifiable for the surgeon to recommend and place another access.

  40. Overcoming Obstacles and Barriers (continued) • Fistula First has a “Payer Packet” (Found on Fistula First website) Includes: • Flyer explaining about the Fistula First Breakthrough Initiative, why this program matters, and what the insurance company can do. • Summary of Recommendations • FFBI Priority Recommendations • Graphs/charts on vascular access costs

  41. Overcoming Obstacles and Barriers (continued) • Fistula First Sample Letter for PCP or Insurance companies (Found on the Fistula First website) • Encourage patients to become an advocate for their care. Involve SW to assist patient on what to discuss with the insurance company.

  42. Overcoming Obstacles and Barriers (continued) No surgeons/good surgeons in the area: Education: • Nephrologists and the facility (Medical Director, Manager or Vascular Access Coordinator) speak with surgeons about the Fistula First program and the facility’s expectation of the surgeon to meet goals of the Fistula First program. • Refer surgeons to the Fistula First website for resources including the surgical video “Creating AV Fistulae in All Eligible Hemodialysis Patients”

  43. Overcoming Obstacles and Barriers (continued) Education (continued): • Share the Cannulation DVD with the surgeons so that they understand the logistics of cannulation and can position the veins suitably and safely for cannulation. Communication: • If facilities in the same area use the same surgeon(s), all facilities should communicate the same message/urgency regarding AVF placement.

  44. Overcoming Obstacles and Barriers (continued) Communication (continued): • The San Diego and Orange County areas have Dialysis Access Club meetings in which any surgeons, interventional radiologist, nephrologists, and dialysis staff can attend. These meetings are a great open discussion forum for issues in accesses creation, complications, etc. that these disciplines can discuss. • Nephrologists can discuss with their colleagues about which surgeons they utilize and how well those surgeons perform.

  45. Overcoming Obstacles and Barriers (continued) Process: • If you have access to a Vascular Access Center, use those facilities for AVF evaluations - vein mapping – and communicate results with surgeons. You can also use the centers for follow-up after an AVF placement to ensure the access is maturing. • Implement Change Concept #4: Surgeon selection based on best outcomes, willingness, and ability to provide access services.

  46. Overcoming Obstacles and Barriers (continued) Process (continued): • The facility should develop a tracking system to monitor their surgeon’s performance. • This can be used to: • Determine continued referral to that surgeon • Develop a “report card” for that surgeon • Discuss with the surgeon how to improve performance or technique – referral to resources.

  47. Overcoming Obstacles and Barriers (continued) Process (continued): • Encourage nephrologists to refer patients for evaluation while the patient is still in the hospital. • If unable to do prior to discharge, encourage the nephrologist to schedule an appointment for outpatient evaluation.

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