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Report from the Executive Director

Report from the Executive Director. Glenda Harbert, RN, CNN, CPHQ. MISSION Statement. The ESRD Network of Texas, Inc. supports quality dialysis & kidney transplant healthcare through patient services, education, quality improvement & data exchange. 2003. ESRD Network #14.

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Report from the Executive Director

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  1. Report from the Executive Director Glenda Harbert, RN, CNN, CPHQ

  2. MISSION Statement The ESRD Network of Texas, Inc. supports quality dialysis & kidney transplant healthcare through patient services, education, quality improvement & data exchange. 2003

  3. ESRD Network #14 The 2ndlargest Network in number of dialysis patients (35,415) behind Network 6 (37,143) The 3rdlargest Network in number of dialysis Providers (456) behind Network 6 (561) & Network 9 (490).

  4. Topics • Network activities • TEEC • DSHS Referrals • The Future

  5. Activities of the Network • Quality Improvement • Community Information & Outreach • TEEC & Disaster preparedness • Patient & Provider Technical Assistance & Education • Complaints & Grievances • Averting Involuntary Discharge • Information Management

  6. Quality Improvement • Quality Improvement Projects • Improving Phosphorus • Quality of Care Concerns, Elab Data Collection & CPM’s • Vascular Access Improvement Projects • 2 year outliers for clinical labs • Adequacy of HD

  7. Community Information & Outreach

  8. What is TEEC? The mission of TEEC is to ensure a coordinated preparedness, plan, response and recovery to emergency events affecting the Texas ESRD community.

  9. Brian Sanders, RN. MBA (Network 14 liaison) John Dahlin Eugenia De Los Reves, RN Balbi Godwin, RN (Chair-Elect) Vanessa Guillory, RN (Chair) Glenda Harbert, RN (ED for Network 14) Courtney Harman Kelley Harris Doug Havron, RN Debbie Heinrich, RN Becky Heinsohm, RN (consultant) Derek Jakovich, JD (consultant) Robert Leggington, MD Minnie Malone, RN (consultant) Connie Oden, RN Glenda Payne, RN (consultant) Alex Rosenblum, RN Narendra Singh Steven Tays Jeff Thompson, MD Karen Walton, RN Mikki Ward, RN TEEC Steering Committee

  10. Coastal Counties June 6, 2010 184 Facilities 14, 715 Patients

  11. Pre-Hurricane Preparations • Independent facilities must pre-plan for backup dialysis with another provider • Patients should be STRONGLY encouraged to evacuate • Any patient with limited mobility, support systems and or transportation MUST be registered for evacuation with 211 • Telling patients to go the hospital for dialysis is NOT a disaster plan!

  12. Annual Preparations • Mail-out from NW • Template Disaster Plan • Forms • Letters • Checklists for pre & post disaster • Drills with EMSystem & DSHS • Webinar & mentoring for independent facilities

  13. The packet informed me of the: Resources provided will be used to: #responses: 260

  14. My facility will make the expected disaster preparations

  15. % of Compliant FacilitiesEMSystems – 07/2009 to 03/2010

  16. % of Compliant FacilitiesEMSystems - 07/2009 to 03/2010

  17. Complaints, Grievances & Involuntary Discharge (IVD)

  18. NW 14 Trends in “negative contacts”Percent of total

  19. “Drill down” of Quality of care beneficiary complaints and inquiries 09-10 New focus on caring Communications

  20. Trending Number of Complaints by Facility 14% decrease 08-09 in facilities with 1 complaint

  21. Trends in complaints

  22. Cause of Formal Grievance 3 FG 2007, 8 FG 2008, 5 FG 2009

  23. Trending Involuntary Discharge • 3 year trend in increase reversed • 22% decrease in # pts • 15% decrease in # facilities with IVD Rate remains < 0.1% of total patients

  24. Averted IVD’s 7/09- 6/10 • 12

  25. Information Management

  26. What happened to Crown Web? • Phase II- Pilot Project with all Networks & 10 Facilities each • Full Implementation ?? • For more information • Visit CW booth • Attend last session Saturday

  27. DSHS Referral Update

  28. Number of Cases & Levels

  29. Common Themes • Unsafe Infection Control Practices • Simultaneous care of Hepatitis B negative and Hepatitis B positive patients • Failure to follow vaccination program • Poor hand washing practices • Inappropriate use of Personal Protective Equipment (PPE) • Not disinfecting surfaces • Failure to implement Quality Assessment and Performance Improvement (QAPI) • Lack of tracking, trending and analyzing • Inconsistent participation of Interdisciplinary team members • Failure to recognize, report and track Adverse Events

  30. Common Themes • Patient Safety Concerns • Lack of patient assessments (pre, during & post) • Lack of staff knowledge regarding emergency equipment • Vascular Access Outliers • High Catheter Rate/ Low AVF Rate • Unsafe Physical Environment • Dirty floors, broken tiles • Insects • Unlabeled hazardous chemicals • Water Treatment Practices • Not testing properly • Lack of staff knowledge • Unsafe Reuse practices

  31. Communication Issues • Nurses not following Physician’s orders • PCT’s not reporting critical treatment data/events to nurses: • Failure to report • Hyper & Hypo tension pre, during, and post dialysis treatments • Initiating Sodium Profiling with  BP • Failure to: • obtain accurate weights • identify wet transducers • communicate “Reportable Parameters” to physician or nurse

  32. Percent of DSHS Referral Facilities that Met MRB Cut Points at Year End

  33. Percent of DSHS Referral Facilities With Improved Outcomes Using Most Current Data

  34. Percent of DSHS Referral Facilities With Improved Outcomes 14/19 (73.7%) with improvement in fewer than 4/4 indicators met or exceeded MRB QOC cut point at time of referral

  35. Patients directly impacted with improved outcomes DSHS referrals • 494 patients with improved outcomes • Removal of Catheter > 90 days • AVF placed • Anemia improved • HD Adequacy improved • 2,513 patients potentially impacted

  36. Future • Healthcare Acquired Infections (HAI) • Catheter Reduction • Disparities • Vulnerable populations

  37. Coming soon DVD for patients • Short • Diverse patient presenters • Highlights benefits of exercise

  38. Giving thanksThere is always something to be thankful for What didn’t happen

  39. “swine flu” H1N1 & the dialysis setting

  40. No Devastating Hurricane Galveston Island Post Ike

  41. Thank you for all that you do gharbert@nw14.esrd.net 469-916-3801

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