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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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slide1
Clinical Indicator Goals: Are You on Target?

Svetlana (Lana) Kacherova, QI Director

July 30 & 31, 2008

health care quality improvement program hcqip
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)
esrd network national goals
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

esrd network national goals6
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

network 18 mission statement
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.

network 18 definition of quality
Network 18 Definition of Quality

“Doing the right thing correctly

the first time.”

patients in our network 2006 2007 annual report
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
delivering care to dialysis patients
Delivering Care to Dialysis Patients
  • Dialysis Facilities – (n=305)
    • Ownership
      • Large Corporate (LDO) - 157
      • Non-Corporate (Independent) - 148
    • Location
      • Freestanding
      • Hospital
goals established by the esrd network based on
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
clinical performance goals
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
esrd clinical performance measures cpm project
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)
five major domains of care
Five Major Domains of Care:
  • Adequacy of Dialysis
  • Anemia Management
  • Nutritional Status
  • Bone and Mineral Metabolism
  • Vascular Access
adequacy of dialysis
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
adequacy of dialysis adult hd pts urr
Adequacy of Dialysis: adult HD pts (URR)

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

adequacy of dialysis adult hd pts kt v
Adequacy of Dialysis Adult HD pts (Kt/V)

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

2007 annual report opportunities to improve adequacy
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
2007 cpm results pediatric hd patients adequacy
2007 CPM Results Pediatric HD Patients: Adequacy

Opportunities to improve Clearance:

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

2007 cpm results pediatric pd patients clearance
2007 CPM Results Pediatric PD Patients: Clearance

Opportunities to improve Clearance:

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

anemia management adult hd pts hgb
Anemia Management Adult HD pts (Hgb)

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

2007 annual report opportunities to improve anemia management
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
2007 cpm results pediatric hd patients anemia management
2007 CPM Results Pediatric HD Patients: Anemia Management

Opportunities to improve Anemia:

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

2007 cpm results pediatric pd patients anemia management
2007 CPM Results Pediatric PD Patients: Anemia Management

Opportunities to improve Anemia:

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

nutritional status adult hd patients
Nutritional Status Adult HD patients

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).

2007 annual report opportunities to improve serum albumin
2007 Annual Report: Opportunities to Improve Serum Albumin
  • 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
2007 cpm results u s adult pd patients serum albumin
2007 CPM results U.S. Adult PD patients: Serum 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

2007 cpm results pediatric hd patients serum albumin
2007 CPM Results Pediatric HD Patients: Serum Albumin

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

2007 annual report opportunities to improve vascular access
2007 Annual Report: Opportunities to Improve Vascular Access
  • 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
what is the most visible qi project in network 18
What is the most visible QI project in Network 18?
  • Fistula First (Fistula First Breakthrough Initiative)
fistula first goal
“Fistula First” GOAL

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!

fistula first goals avf rates
Fistula First Goals (AVF Rates)
  • 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%

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 AFG patients

AVF evaluation/placement in catheter pts

Cannulation training

Monitoring and maintenance

Continuing Education

Outcomes feedback

Tools & Best Practices:Fistula First Change Concepts
new conditions for coverage qapi quality assessment and performance improvement
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!
pdca style
PDCA Style

ACT

PLAN

CHECK

DO

qapi program requirements
QAPI Program requirements
  • Action-oriented
  • Data-driven
  • Under the direction of Medical Director
  • Requires RN and interdisciplinary team participation
  • Quality Improvement Committee
slide53
Quality Improvement Activities

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
slide54
CMS-Approved QIPs
  • Anemia Management
  • Hepatitis B Vaccination
  • AV Fistula Placement
  • Hemodialysis Adequacy
  • Stenosis Monitoring (100%)
  • Fistula First
slide56
Svetlana (Lana) Kacherova

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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