Quality Improvement Overview
Quality Improvement Overview
A primary goal of the ESRD Networks is to improve the quality of health care services provided to ESRD beneficiaries. Network 8 utilizes various strategies to achieve this goal, such as development and coordination of quality improvement projects, provision of data feedback reports, offer of technical assistance by Network 8 QI staff and Medical Review Board, and provision of educational opportunities and materials.
Areas in need of improvement in Network 8 are identified by:
- CMS direction
- Patient and facility communications
- Various data collections and reports
- State surveyor and QIO collaborations
- Input from renal community and Network 8 boards
These areas may be addressed through general measures for all facilities, such as posting educational materials on the website, or by specific Network intervention with targeted facilities, practitioners or regions.
The CMS Conditions for Coverage require each facility to participate in the Network CQI activities, as well as establish their own Quality Assessment and Performance Improvement (QAPI) program to include, as described in the Interpretive Guidance:
- Monitoring data/information
- Prioritizing areas for improvement
- Determining potential root causes
- Developing, implementing, evaluating and revising plans that result in improvements in care
Quality of care issues to be addressed by facilities include, but are not limited to, dialysis adequacy, nutritional status, mineral metabolism and renal bone disease, anemia management, vascular access, medical injuries and identification of medical errors, hemodialysis reuse program (if applicable), patient satisfaction and grievances, and infection control issues.
Additional information and assistance with QAPI activities may be obtained by contacting the QI staff at the Network office.
Current Network 8 Quality Improvement Projects
- Fistula First Breakthrough Initiative
- Decreasing Central Venous Catheters
- Anemia Management
- Additional quality improvement activities address other Clinical Performance Measures as listed below.
- Increasing Influenza Immunizations Project
Goals for Clinical Performance Measures/Quality Indicators
Utilizing data collected from facilities, Network 8 profiles facility performance in accordance to the following goals established by CMS and the Network 8 Medical Review Board, for the current Clinical Performance Measures. Facilities will be notified as changes are made to the goals and/or measures.
Measure |
*Network 8 Goal |
Network Intervention Level |
Standardized Mortality Rate (SMR) |
≤ 1.0 |
> 1.0 with significant p-value |
Vascular Access:
|
** ≥ 58%
|
AVF use rate < 58% LTC rate > 15% |
Anemia Management
|
< 11% |
> 20% with Hgb > 12.0 |
Hemodialysis Adequacy:
|
≥ 95% |
< 84% (CMS goal) patients with spKt/V ≥ 1.2 or |
- * Network 8 goals are reviewed annually with revisions as indicated by Network-wide facility performance. Revisions of goals are posted to Network 8 website as they occur.
-
** 58% of prevalent patients using AVF is the Network 8 short-term goal, which was increased in June 2011 by the Medical Review Board in an effort to meet the CMS "stretch" goal of 66%.
- Network goals are consistent with the Measures Assessment Tool (MAT) contained in the Conditions for Coverage, released 10-2008; the most recent version, Interim Final 1.9, modified 10-2011 and is located here.
Available Resources from Network 8
Click here to view the contents of the Network 8 electronic toolkit.
To send an email request for toolkit, click here.
5 Diamond Patient Safety Program
In order to encourage patient safety values, Network 8 announces availability of the voluntary 5-Diamond Patient Safety Program. Initially developed and implemented in the Network of New England (NW1) and the Mid-Atlantic Renal Coalition (NW5), this program is designed to assist dialysis units with specific areas of patient safety that may be in need of improvement and consistency. Click here to read about the benefits of participating in this self-paced recognition program.