Category: All Networks

Learn New Approaches to Healthcare Improvement Using IHI’s Framework

To support your participation in the Network’s 2018 quality improvement activities (QIAs), we invite you to review the Institute for Healthcare Improvement’s (IHI) Model for Improvement, an approach that IHI uses as the framework to guide improvement work. Developed by Associates in Process Improvement, the Model for Improvement is a simple, yet powerful tool for accelerating improvement. It is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.

Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Additionally, root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred.

To learn more about the Quality Improvement Essentials Toolkit and view all available tools, visit http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx

Implementation of the CDC CORE Interventions Saves Lives

The Centers for Disease Control and Prevention reports infection is the second most common cause of death and hospitalization among dialysis patients.  Hemodialysis patients have multiple and frequent exposure to healthcare environments undergoing treatment three times per week with direct access to their bloodstream via venipuncture and catheters.  Healthcare expenditures for these infections are staggering. Research has shown that the Implementation of the CDC core interventions reduces infections dramatically, saving lives and reducing healthcare costs.  Take a minute to review these interventions, by clicking here, to assure your facility is doing everything possible to be safe and save lives.

February is National Heart Month

Heart disease can often be prevented by identifying risk factors and making healthy lifestyle choices. Help ESRD patients reduce their risk. Recommend appropriate preventive services, including cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease.

For More Information:
Preventive Services Educational Tool
Million Hearts®: Resources to help educate, motivate, and monitor your patients
Centers for Disease Control and Prevention Heart Disease website

Visit the Preventive Services website to learn more about Medicare-covered services.

Have you Completed your Annual NHSN Dialysis Event Surveillance Training?

The NHSN is an electronic tracking system for healthcare-associated infections (HAIs) that integrates patient and healthcare personnel surveillance systems managed by the CDC. To fulfill the annual NHSN training requirement, at least one NHSN user at each facility must read the Dialysis Event Protocol and subsequently take the online Dialysis Event Surveillance Training before September 30, 2018. By completing the Annual Training and passing the post-training assessment, individuals are eligible to earn continuing education credits (CE), provided they complete this process online.

CROWNWeb End Users: Upcoming ESRD QIP Data Validity and Reliability Study

The Centers for Medicare & Medicaid Services (CMS) has contracted with RELI Group to assess the reliability and validity of the Clinical Performance Measure (CPM) data entered into the CROWNWeb system and Dialysis Event data entered into the Center for Disease Control (CDC) NHSN system. RELI will be randomly selecting 335 ESRD facilities to participate in this validation effort. Of those selected, 300 facilities will be sampled to submit records pertaining to CROWNWeb data and 35 facilities will be sampled to submit records pertaining to NHSN data.

If your facility is not selected for validation, there is nothing more to do. If your facility is selected to participate in the validation you will receive a Request Letter via USPS Certified Mail. These requests are scheduled to go out in February 2018. If you are part of a Large Dialysis Organization (LDO), your corporate office may receive your request and contact you for any necessary records.

Please note: you will be required to sign for the letter; if no one is available to sign at the time of delivery, the US Post Office for your area will hold the letter until you are able to retrieve it. In this case, a notice will be left at your facility.

The Request Letter will include:

  • The list of patients sampled from your facility (maximum of 10)
  • The list of records you will need to submit
  • A thorough explanation of the submission process to ensure that all records are submitted to RELI in a secure manner

Facilities that do not respond to this request will receive a 10-point reduction in their End-Stage Renal Disease Quality Incentive Program Total Performance Score (ESRD QIP TPS).

For questions on the Upcoming ESRD QIP Data Validity and Reliability Study, contact Gladys Happi, MSN, RN, CNN, ESRD Clinical Data Lead/Deputy PM at ghappi@hcdi.com.

 

ESRD QIP Payment Year (PY) 2019 CROWNWeb Reporting and Attestation Deadline

The Calendar Year (CY) 2017 End-Stage Renal Disease Prospective Payment System (ESRD PPS) Final Rule requires facilities to report data into CROWNWeb before the clinical month closure.  As a reminder, all CROWNWeb reporting and attestations for the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) are due at the end of the last clinical month of the reporting period.

The second reporting period for the ESRD QIP Payment Year (PY) 2019 Pain Assessment and Follow-Up and Clinical Depression Screening and Follow-Up reporting measures, and the attestation period for the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey measure close on February 28, 2018, at 11:59 PM Eastern Time, which is in alignment with the December 2017 clinical month closure.

For upcoming deadline information, please see the monthly editions of the CROWNWeb Newsletter or ESRD QIP page on MyCROWNWeb.org” href=”http://r20.rs6.net/tn.jsp?f=001IYm3265Ea2-jhGBquyTSeMXKPeruW1Mu2hgf-RRhN6YRQOVkzWXioaofvRzC7Mniuj8zgfJ5D2f7Gujg3OqXJZeJ8Wfvssc3_oTnymZx9oUAdmIiYlG9xjDafSs9eWI8sT6JheZI_aPsGM6Oz3SX18_tARgSP4hywtez6ZEmf6Lo4N6UKJ8eF2KFffs43P2l45Fwy700wbaMmmgEAq-oSA==&c=C9y7cEQmMuz9fOBr6g2Jl50rzDFSaRza65EoGA2k0IhvxRBI9Kiy9g==&ch=KmrX_6AQMUqHL3yR3tTAL8T5bk7Xtey9_hTxreWsx5JLQ61qkLLdvA==” target=”_blank” rel=”noopener”>ESRD QIP page on MyCROWNWeb.org.  If you have any questions or concerns, please contact the ESRD QIP team at esrdqip@cms.hhs.gov.

NHSN Dialysis Event Surveillance Instructions for Acute Kidney Injury (AKI) Patients

Beginning January 1, 2018, dialysis facilities should include acute kidney injury (AKI) patients in National Healthcare Safety Network (NHSN) Dialysis Event Surveillance.  Reporting AKI patient data to a new, separate NHSN location will enable CDC to exclude AKI patient data from NHSN Bloodstream Infection (BSI) information shared with CMS for purposes of the ESRD Quality Incentive Program (QIP).

The “Acute Kidney Injury (AKI) Location” should be used to report Dialysis Events, and denominator data for patients who have acute kidney injury and do not have an end-stage renal disease (ESRD) diagnosis at the time of the Event, or at time of denominator data collection.

The “Acute Kidney Injury Location” was released as part of the NHSN version 8.8 update on December 2, 2017.  Please click here for instructions on using the “Acute Kidney Injury Location”.

Of those included in the NHSN Dialysis Event Surveillance population, the following criteria should be used to identify patients who have acute kidney injury:

1. No diagnosis of “End Stage Renal Disease” or “ESRD” in the patient medical record, or through the ESRD Medical Evidence Form (Form CMS-2728-U3).

AND

2. Physician-diagnosis of “Acute Kidney Injury: or “AKI” listed in the patient medical record (e.g., nephrologist consult or referral form).

AND

3. The event date, or date of denominator data collection, is not more than 6 months after the date the patient initiated outpatient hemodialysis.

For questions, please contact the NHSN helpdesk: nhsn@cdc.gov with “dialysis” in the subject line.

Extension of NHSN Third-Quarter 2017 Deadline for ESRD QIP

After the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) system release on December 2, 2017, analysis reports and select alerts were not accessible to some NHSN Dialysis Component group and facility users. This issue has since been resolved, and users are now able to access their reports and receive alerts.

As a result of this issue, outpatient dialysis facilities and groups were unable to review NHSN data for completion and accuracy from December 2, 2017 through December 21, 2017. To provide facilities with ample time to review their NHSN data and make any corrections, CMS has extended the ESRD QIP deadline for facilities to enter third-quarter 2017 NHSN data to January 31, 2018.

For more information on the ESRD QIP, please visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/index.html. For more information about NHSN, please visit https://www.cdc.gov/nhsn/dialysis/.

Thank you for your attention in this matter and for entering your facility’s data promptly. If you have any additional questions or concerns, please contact the NHSN helpdesk at  mailto:NHSN@cdc.gov or CMS ESRD QIP team at esrdqip@cms.hhs.gov.

Identifying and Addressing Barriers for ESRD Beneficiaries

A 2013 study on the ESRD beneficiary grievance process, The ESRD Beneficiary Grievance Process (OEI-01-11-00550) conducted by the U.S. Health and Human Services, identified deficiencies at facilities across the country.  Because of this study, the following five  recommendations for improvement were made to CMS: 1) define “grievance” for facilities, 2) require that facilities report grievances regularly to their respective networks, 3) provide guidance to facilities on what constitutes a robust process for anonymous grievances, 4) work with the Agency for Healthcare Research and Quality to add a question to the standardized satisfaction survey to assess ESRD beneficiaries’ fear of reprisal, and 5) provide networks with better technical support for their grievance database. Of these recommendations CMS is working to address barriers related to the definition of a grievance, what constitutes a robust process for anonymous grievances, and proving better technical support for the grievance database. It is important for patients to be able to file a grievance without fear of reprisal.  In order to reduce the fear of reprisal, all facilities must develop an anonymous internal grievance process that allows patients, family members, or caregivers to voice their concerns. According to CMS guidelines, in an anonymous grievance, the identity of the person(s) will remain unknown to the facility. Patients should be educated that the facility is unable to contact an anonymous grievant to inform them of the steps taken to investigate the grievance or the outcome of the investigation. In these cases, the grievant should be advised of the following:

  • The grievance will be investigated, but the facility will be unable to report back to them, unless a name and address is provided.
  • Because of the small population in dialysis facilities, the provider involved may be able to identify the grievant, even when anonymity is maintained.
  • The investigation may be limited due to minimal amount of information available to the facility.

 

Facility Involvement in Learning & Action Networks: A 2018 CMS Requirement

All facilities participating in Network QIAs are required to participate in national Learning & Action Networks (LANs) to support QIA activities. LANs provide a forum for bringing together healthcare professionals, patients, and other stakeholders around an evidence-based agenda to achieve rapid, wide-scale improvement.

Staff members at facilities participating in QIAs will be asked to participate in ESRD National Coordinating Center (NCC) LAN webinars associated with the QIA their facility is working on.  The Network may also select additional facilities that may benefit from an identified LAN topic. Patients and their family/caregivers will also be asked to participate in an effort to advance the work of the QIA.

The ESRD NCC LAN will support facilities in more efficiently achieving the goals of the QIAs and sustaining the improvements, by:

  • Creating a diverse forum (patients, organizations, and stakeholders) for addressing problematic issues
  • Using measurable and clear goals with proven effective practices to drive decision making
  • Setting the pace and tone for goal related activities and to create an open sharing of practice and data

Initiating change methodology which rapidly tests small quality improvement changes specific to the area of work

CDC Making Dialysis Safer for Patients Coalition

The Making Dialysis Safer for Patients Coalition is a partnership of organizations and individuals that have joined forces with the common goal of promoting the use of the Centers for Disease Control and Prevention’s (CDC) core interventions and resources to prevent dialysis bloodstream infections. CDC’s core interventions have been proven to reduce the number of infections by half and be sustainable.  The CDC has also developed a set of audit tools, checklists, and other resources to help facilitate adoption of these critical core interventions.

The IPRO ESRD Network Program is pleased to announce that we have now joined the CDC Making Dialysis Safer for Patients Coalition.

To learn more about the Coalition and how to become a partner or member please visit: https://www.cdc.gov/dialysis/coalition/index.html.

Understanding the 2018 End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

CMS implemented the ESRD QIP in 2012 to help ensure that high quality healthcare is provided to all ESRD patients by incentivizing dialysis facilities through pay-for-performance based on the quality of care they deliver.  There are 16 measurements for the 2018 calendar year (CY), which will reflect in the 2020 payment year (PY). These measures should be reviewed monthly and discussed with the healthcare team at QAPI meetings.  Measures are separated into the following three components:

Clinical:
* ICH CAHPS
* Standardized Readmission Ratio
* Kt/V Dialysis Adequacy (comprehensive)
* Standardized Transfusion Ratio
* VAT Measure Topic (fistula, catheter)
* Hypercalcemia
* Standardized Hospitalization Ratio

Safety:
* NHSN BSI Measure Topic (NHSN BSI clinical, Dialysis Event reporting)

Reporting:
* Serum Phosphorus
* Anemia Management
* Pain Assessment and Follow-Up
* Clinical Depression Screening and Follow-Up
* NHSN Healthcare Personnel Influenza Vaccination
* Ultrafiltration Rate

Additional information about the ESRD QIP:

Network staff members are available to assist facility staff in overcoming  any barriers in achieving these measures.