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Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
Fistula First Quality Improvement Project
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Fistula First Quality Improvement Project

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  • 1. Vascular Access (Fistula First) Quality Improvement Project CMS has identified increasing fistula rates as a national breakthrough priority. Evidence-based literature indicates that AV fistula is the preferred access for hemodialysis based on lower complication rates, longevity, and lower costs. CMS has set a national goal of at least 66% of prevalent patients using an AV fistula. CMS has set ESRD Networks specific goals for continual improvement in this area. Specifically, each ESRD Network must decrease their quality deficit by 20% by the end of each year of the contract. Network 2’s baseline rate from March 2009 data (May 2009 Dashboard) is a 55.6% fistula use rate in prevalent patients. Therefore, Network 2’s quality deficit is 10.4% (66%–55.6%). For option year three (3) of the contract, Network 2 must reduce the quality deficit by 2.1% (20% x 10.4). As illustrated in the chart below, Network 2’s fistula goal for this year is 57.7%. Source: Fistula First Outcomes Dashboard This contract year, Network 2 will focus on the facilities that are performing poorly while continuing to support all of the facilities. Network 2 will supply the facilities with educational materials and offerings as well as feedback reports on how they are performing. The low- performing facilities will submit QIPs to Network 2. These facilities will be supported through conference calls and/or site visits. Quality Improvement Work Plan Task 1.a Vascular Access Quality Improvement Work Plan Task 1.a Vascular Access Project Lead Carol Lyden, RN, BSN, MS, CNN, Quality Improvement Coordinator Project The contract requirement for Network 2 is to have an AV fistula rate of 57.7% by March 31, Description 2010. This will require an increase of 2.1% or appropriately 0.18% each month from the May 2009 Dashboard (March 2009 data) to the May 2010 Dashboard (March 2010 data). Last contract year, Network 2 met the AV fistula goal of 55.3% by March 2009 for the first time in the 3-year contract cycle, even though many Networks did not meet their goals. To meet this year’s goal, Network 2 has developed a comprehensive plan. The QIWP will include: § Education on Vascular Access for patients and professionals § Quarterly report cards to the nephrologists on accesses in place at initiation of dialysis § Quarterly reports sent to the facilities on access placement benchmarked to Network 2 and the nation § Quarterly report cards to the facilities on catheters > 90 days
  • 2. § Request for QIPs for facilities with o deceased number of AV fistulas below 46% o increased number of catheters > 90 days above 18% o a decline in AV fistula rates for 3 months or more § Site visits to targeted facilities that do not show improvement of at least 1% § A goal based on the quality deficit formula in the ESRD Network contract Background CMS has identified AV fistula use as a breakthrough initiative. CMS has set a national stretch goal of 66% AV fistula rate for prevalent patients by June 2009 and a goal of 50% AV fistula rate in incident patients. This goal is supported by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for Vascular Access. As of the May 2009 Dashboard (March 2009 data), the national AV fistula rates used in prevalent patients is 52% and those in incident patients is 31.7%. As of the same time frame, Network 2’s AV fistula rate used in prevalent patients is 55.6% and those in incident patients is 37.1%. The National Vascular Access Improvement Initiative was adopted to obtain the goal of increasing the appropriate use of AV fistulas for hemodialysis access. A group chaired by Larry Spergel, MD (vascular surgeon), which included community stakeholders—ESRD Networks, corporate and independent dialysis providers, health care professionals, CMS, and the Institute for Healthcare Improvement (IHI)—developed a set of 11 key change concepts. The purpose of this change concepts package is to assist in the clinical and organizational improvement required to increase the use of AV fistulas. Network 2 will focus its Fistula First activities, such as QIPs and site visits, based on these change concepts: 1. Routine Continuous Quality Improvement review of Vascular Access 2. AV fistula placement in patients with catheters, where indicated 3. Cannulation training for AV fistulas 4. Monitoring and maintenance to ensure adequate access function 5. Education for caregivers and patients 6. Outcome feedback to guide practice Facilities that are required to submit a QIP and who are not showing improvement should do a root cause analysis and should use the FFBI change package to assist them in developing an effective plan. In March 2009, the FFBI contract was awarded to Network 5. They were required to do a root cause analysis (RCA) with key stakeholders. The three main areas of opportunity to improve AV fistula rates was the decision to place access other than AV fistula, inability to use the AV fistula once placed, and failure to construct secondary AV fistulas when indicated. On May 27, 2009, CMS requested that the Networks complete a root cause analysis related to the AV fistula rates and to submit it by June 2, 2009. The Network made recommendations to give each facility an AV fistula goal, to request QIP from low-performing facilities, as well as facilities with declining performance, and to work with Large Dialysis Organization (LDO) management to improve AV fistula rates in their facilities. In the development of this year’s QIWP for improving Vascular Access, the Network will focus some of it interventions on the
  • 3. findings of these RCA. Goal Network: The goal of Network 2 is to have an AV fistula rate of 57.7% in prevalent patients by March 31, 2010. Targeted Facilities: AV fistula rates to have an absolute improvement in prevalent patients of targeted facilities and/or weighted average improvement of 4 percentage points. Catheter rates to have an absolute improvement for ≥ 90 days of targeted facilities and/or weighted average improvement of 4 percentage points. Measure Network: The measure will be obtained from the Fistula First Dashboard. This data is compiled from the monthly Vascular Access Reports. The independent facilities send these Reports to Network 2, and the LDOs send these Reports nationally, where they are downloaded to the ESRD Networks from CSC. Numerator: The number of prevalent patients in Network 2 with an AV fistula being used for hemodialysis as reported in the Vascular Access Report. Denominator: The total number of hemodialysis patients in Network 2 as reported in the Vascular Access Report. Baseline: The AV fistula rate being used in Network 2’s prevalent patients is 55.6% as of March 2009 data (May 2009 Dashboard). Targeted Facilities AV fistulas: Lowest performing facilities with > 50 patients and AV fistula rate < 46%March 2009 data (May 2009 Dashboard). Numerator: Total number of prevalent hemodialysis patients using an AV fistula in targeted facilities. Denominator: Total number of prevalent hemodialysis patients reported in targeted facility. Baseline Measure: March 2009.
  • 4. Provider Pt Census % Pt AVF # Pt AVF Target Goal 1 91 35.2 32 39.2 2 91 45.1 41 49.1 3 221 35.7 79 39.7 4 61 36.1 22 40.1 5 106 40.6 43 44.6 6 176 35.8 63 39.8 7 64 37.5 24 41.5 8 72 38.9 28 42.9 9 54
  • 5. Methodology Education: 1. Patient a. Articles in PAC Notes b. Presentation at regional PAC meetings c. Distribution of patient information for use by providers to educate patients i. Pamphlet “Vascular Access for Hemodialysis: A Guide for Patients” – in English and Spanish ii. Pamphlet “Fistula First Frequently Asked Questions for Patients and for Families” – in English iii. Poster “Vascular Access for Hemodialysis: A Guide for Patients” – in English and Spanish 2. Professionals a. Vascular Access program, titled: “CE Workshop for Dialysis Staff: Surveillance, Monitoring, and Infection Control” b. Articles in Network Notes c. Distribution of current and relative information to facilities and/or nephrologists with report cards and reports, and upon request d. Distribution of cannulation video, pamphlets, and posters upon request from providers 3. Evaluation a. Educational presentations that offer continuing educational credits will have an evaluation at the end of the program to assess participant satisfaction with the program, effectiveness of each speaker, and requests for future topics. These evaluations will be used to determine the effectiveness of the program and the directions of future programs. b. Educational materials, tools, and presentations without continuing education credits will not be evaluated for effectiveness but will be used for spread of current Vascular Access information. Feedback Reports Sent Out on a Quarterly Basis: This communicates to the facility, staff, and nephrologist that the Network is reviewing their Vascular Access rates quarterly and is comparing the facility’s performance to the Network and/or national average. 1. Vascular Access in Incident Patients: A report will be sent to each nephrologist who signed a minimum of five Medical Evidence Reports for ESRD (CMS form 2728) within the report period. Form 2728 identifies the type(s) of accesses the incident patients had at the initiation of chronic outpatient dialysis. This report will trend over time for the nephrologist the number of incident patients he/she started, the vascular access used at the initiation of hemodialysis, if there is a maturing AV fistula or AV graft in place, if the patients were under the care of a nephrologist prior to the initiation of treatment and if so, for how long before the start of treatment. Their AV fistula rates will be benchmarked against Network 2. The goal of 50% incident patients will be labeled on the graph. 2. Fistula Rate Comparisons and Goals, Prevalent Patients: Facility, Network 2, and National – This report benchmarks the facility to the Network and the Nation and it identifies the goals for each. The report also includes the progress the facility is making toward its individual goal. 3. Vascular Access Used in Prevalent Patients: This report includes a table and graph of
  • 6. the facility’s prevalence rates for use of fistulas, grafts, and catheters/ports. 4. Fistula Use and Placement Rates in Incidence Patients: This report is a table showing the type of access used by the incident patient at his/her first outpatient treatment. 5. Catheter > 90 Days: A report card will be sent to facilities identifying the number of catheters > 90 days. It will include a graph to trend over time the facility’s catheter rate benchmarked to Network 2 catheter rate and the facilities ranking in Network 2 of catheter rate > 90 days. 6. Evaluation of Feedback Reports Will Be Done Annually: The evaluation will be sent out with one of the feedback report mailings. The evaluation will be used to determine if the facility finds these reports valuable and if it utilizes the reports to determine Quality Improvement Projects and/or for reporting at their Quality Improvement meetings. AV Fistula Goal: 1. Each facility will be given a goal to improve the AV fistula rate in prevalent patients based on the contract’s quality deficit formula. a. Facilities will be given a goal between 1% and 4%. b. If the quality deficit is less than 1%, the facilities goal will be 1%. c. If the quality deficit is greater than 4%, the facilities goal will be 4%. 2. Progress of the facilities toward the goal will be monitored quarterly. If a facility shows a decline in fistula rates > 1% for 3 consecutive months (total of 3% or more), they will be contacted by the Network. If the rates continue to decline, a QIP will be requested. (For details, see below: Quality Improvement Plan.) 3. A quarterly report, Fistula Rate Comparisons and Goals, Prevalent Patients: Facility, Network 2, and National, will be sent to each facility indicating its progress toward the goal and benchmarking it to the Network and national average. Quality Improvement Plan: 1. Identify targeted facilities with census > 50 patients a. AV fistula rate in prevalent patients < 46% – March, 2009 data (May 2009 Dashboard) b. Catheter rate > 90 days in prevalent patients >18% c. Facilities that show a decline of > 1% for 3 or more consecutive months (total of 3% or more) 2. A request for a QIP from the identified low-performing facilities will be sent to the medical director via certified return receipt mail and a copy to the nurse manager from the MRB Chairperson. The QIP should be written in the PDCA format (see below). Directions explaining the PDCA format were included with the QIP request. Network 2 will discuss the PDCA Cycle with facilities as requested. The QIP should include: a. P - Recognition of the existence of the problem, identification of the possible root causes of problem b. D - Description of all steps taken to improve performance c. C - Schedule timetables with specific dates for performance review d. A - Implement changes 3. Network 2 to review QIP for completeness and content within 4 weeks of receipt. Network 2 will review the submitted QIP with every facility. If revisions are required, Network 2 will request submission of revised plan within 2 weeks of review.
  • 7. 4. For facilities that have not responded, a fax reminder will be sent to the medical director and the nurse manager/supervisor with a request for submission in 2 weeks. If the facility does not return the QIP, a call will be placed to the facility’s medical director first by the Quality Improvement Coordinator, followed by the Executive Director and then the MRB Chairperson. If all attempts fail, the CMS Project Officer will be notified. 5. Track facilities to identify improvement monthly. Work with facilities that are not showing improvement through conference calls and/or site visits. Site Visit: Prior to the visit 1. Identify facilities that have shown no improvement and/or minimal improvement in AV fistula rates and/or catheter rates > 90 days. Prioritize facilities based on patient population, rate of improvement and geographic location. 2. Review QIPs submitted by facilities. 3. Review monthly Vascular Access Reports. 4. Review Dialysis Facility Report (DFR) to identify the patient population and potential barriers to improving AV fistula rates. 5. Initial Visit a. Plan visit to facility b. Suggested staff to be present – Medical director, administrator, nurse manager, and vascular access team c. Visit will include a review of the facilities data (QIP submitted, monthly vascular access data, and DFR), vascular access records, vascular access policies and procedures, Quality Improvement Meeting minutes, discussions with the staff, and an exit conference d. Set 6-month goal with the facility e. Written recommendations will be sent to the facility f. Request for a revised QIP within 3 weeks of visit 6. Follow-up Visit (if facility did not meet the goal set) a. Plan date for the visit with the facility b. Required staff present – Medical director, administrator, and nurse manager. Suggested staff – vascular surgeons and vascular access team c. Visit will include a review of the facilities data (QIP submitted, monthly vascular access data, and DFR), vascular access records, vascular access policies and procedures, Quality Improvement Meeting minutes, discussions with the staff, and an exit conference d. Set 6-month goal with the facility e. Written recommendations will be sent to the facility g. Request for a revised QIP within 3 weeks of visit Fistula First Steering Committee: Network 2 has established a Fistula First Steering Committee to advise and guide Network 2 on improving fistula rates. This committee will meet four times during this contract year via conference calls. 1. Purpose of the Steering Committee is to assist Network 2 in identifying areas of opportunity in the community to spread Fistula First. At each Fistula First Steering Committee meeting, a review of the existing vascular and environmental scan data will be used to identify the root causes of low AV fistula rates. 2. Vascular surgeon – The Network has been collecting the names of vascular surgeons
  • 8. who are associated with the individual dialysis units. a. Each vascular surgeon who has been identified will receive a letter with information on FFBI, available educational materials, information on the Chronic Kidney Disease (CKD) Prevention Project, and a questionnaire. Questions included are how the Network can support their practice in the placement and maintenance of AV fistulas, what are facilitating factors and barriers to AV fistula placement, and if they are interested in an educational offering. An order form for patient pamphlets, posters and educational materials will also be included in this mailing. b. Follow-up interventions will be discussed with the group after return of the questionnaire. 3. Interventional radiologists – The Network has been collecting the names of interventional radiologists who are associated with the individual dialysis units. A mailing to the interventional radiologists similar to the mailing to the vascular surgeons will be developed and sent out. Collaboration with CKD Prevention Project 1. Monthly meetings to identify and work on areas of collaboration. 2. Poor-performing facilities a. Share list of poor performers b. Discuss strategies to improve identified targeted facilities c. Invite CKD Project staff to site visits to discuss early insertion of AV fistulas 3. Participate in CKD collaborative as related to vascular access Re-Measure The measure will be obtained from the monthly Fistula First Dashboard. The final re-measure will be March 2009 data (May 2009 Dashboard). Network Numerator: The number of prevalent patients in Network 2 with an AV fistula being used for hemodialysis as reported in the Vascular Access Report. Denominator: The total number of hemodialysis patients in Network 2 as reported in the Vascular Access Report. % Improvement = re-measure – measure Will be done monthly after the National Vascular Access Dashboard is updated. The final re- measure will be in May 2010 when the March 2010 data is complete.
  • 9. 2009 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010 Mar Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas % Of Prevalent Patients using AV Fistulas 55.6 55.8 55.9 56.0
  • 10. Timeline Education: 1. Patient a. Articles in PAC Notes – semi-annual, September 30, 2009, February 28, 2010 b. Presentation at regional PAC meetings monthly c. Distribution of publications – upon request 2. Professionals a. CE Workshop for Dialysis Staff: Surveillance, Monitoring and Infection Control – October and November 2009 b. Articles in Network Notes – semi-annual December 31, 2009, May 30, 2010 c. Distribution of current and relative information to facilities and/or nephrologists with report cards and reports – quarterly August 31, 2009, November 30, 2009, February 28, 2010, May 31, 2010 d. Distribution of cannulation video, pamphlets and posters – upon request Feedback Reports: Quarterly August 31, 2009, November 30, 2009, February 28, 2010, May 31, 2010. 1. Vascular Access in Incident Patients 2. Catheter > 90 days 3. Fistula Rate Comparisons and Goals, Prevalent Patients: Facility, Network 2, and national. 4. Vascular Access Used in Prevalent Patients 5. Fistula Use and Placement Rates in Incidence Patients AV fistula goal: May 2009 Quality Improvement Plan: 1. Mailing – June 20, 2009 2. Requested back to Network – July 20, 2009 3. Review with facility – within 4 weeks of receipt Site Visits: 1. Review Vascular Access Reports – monthly 2. Identify facilities that have shown no improvement in the catheter AV fistula rates and/or catheter rates > 90 days – September 30, 2009 3. Plan visit to facility – based on priority to begin in October 1, 2009. 4. Written recommendations will be sent to the facility – within 2 weeks after visit. 5. Request for a revised QIP to be submitted within 3 weeks of the visit. 6. Review QIP for completeness and content within 2 weeks of receipt. If revisions are required, the Network will contact the facility to review QIP and request submission of revised plan in 2 weeks. 7. Continue to monitor facilities for improvement – monthly 8. If facility shows no improvement, plan a second site visit – 6 months after initial visit. Fistula First Steering Committee: 1. Meetings – quarterly – July 29, 2009, October 28, 2009, January 27, 2010, April 28, 2010 2. Vascular surgeon mailing – July 2009 3. Interventional radiologist mailing – September 2009 Project Reports Report to CMS via Quarterly Progress and Status Report, Annual Report and MRB and BOD meetings

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