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08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
08 Am09 Presentations   Kliger
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08 Am09 Presentations Kliger

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  • Transcript

    • 1. Conditions for Coverage 2008 Interpretive Guidelines Requirements of the Medical Director
    • 2. Major Areas of Responsibility for Medical Directors <ul><li>Patient Assessment </li></ul><ul><li>Quality Assessment &amp; Performance Improvement Program (QAPI) </li></ul><ul><li>Staff Education, Training and Performance </li></ul><ul><li>Policies &amp; Procedures </li></ul><ul><li>Infection Control </li></ul><ul><li>Discharge and Transfer Policies </li></ul>
    • 3. Major Responsibilities of Medical Director <ul><li>Participate in the development, periodic review and approval of patient care policies and procedures manual </li></ul><ul><li>Ensure adherence to all policies and procedures </li></ul><ul><li>Ensure that the ICT adheres to discharge and transfer policies and procedures </li></ul><ul><ul><li>The medical director must monitor and review each involuntary patient discharge to ensure that the ICT follows policies </li></ul></ul>
    • 4. Major Responsibilities of Medical Director <ul><li>Oversight of Patient Care Delivery &amp; Outcomes </li></ul><ul><ul><li>Attend and participate in multidisciplinary meetings </li></ul></ul><ul><ul><li>Participate in performance improvement plans </li></ul></ul><ul><ul><li>Involved in the education of staff </li></ul></ul>
    • 5. Patient Assessment <ul><li>ICT must perform an initial patient assessment within 30 calendar days or 13 outpatient dialysis sessions </li></ul><ul><li>Reassessment </li></ul><ul><ul><li>Annually for “stable patients” </li></ul></ul><ul><ul><li>Monthly for “unstable patients” </li></ul></ul>
    • 6. Unstable Patients Monthly Assessments Needed <ul><li>Extended or frequent hospitalizations </li></ul><ul><li>Marked deterioration in health status </li></ul><ul><li>Significant change in psychosocial needs </li></ul><ul><li>Poor nutritional status </li></ul><ul><li>Unmanaged anemia </li></ul><ul><li>Inadequate dialysis </li></ul>
    • 7. Patient Plan of Care <ul><li>Frequency: Annually if stable Monthly if unstable </li></ul><ul><li>Components of Plan of Care </li></ul><ul><ul><li>Dose of dialysis </li></ul></ul><ul><ul><li>Nutritional status </li></ul></ul><ul><ul><li>Mineral metabolism </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Vascular access </li></ul></ul><ul><ul><li>Psychosocial status </li></ul></ul><ul><ul><li>Modality </li></ul></ul><ul><ul><li>Transplantation status </li></ul></ul>
    • 8. Patient Plan of Care <ul><li>If the expected outcome is not achieved, the ICT must adjust the plan of care to achieve specified goals. </li></ul><ul><li>The ICT must document reasons why the patient is unable to achieve goals and implement plan of care changes to address the problem </li></ul>
    • 9. Infection Control <ul><li>Analyze and document incidence of infection </li></ul><ul><li>Develop recommendations and action plans to minimize infections </li></ul><ul><li>Take action to reduce future incidents </li></ul>
    • 10. Major Responsibilities of Medical Director <ul><li>Time Requirement </li></ul><ul><ul><li>Director should have “some idea” of time </li></ul></ul><ul><ul><li>Guideline: 0.25 FTE </li></ul></ul>
    • 11. QAPI <ul><li>Quality Assessment &amp; Performance Improvement Program </li></ul>
    • 12. QAPI <ul><li>Facility must develop, implement, maintain and evaluate an effective data driven QAPI program </li></ul><ul><li>Focus </li></ul><ul><ul><li>Improved health outcomes </li></ul></ul><ul><ul><li>Reduction of medical errors </li></ul></ul><ul><li>Must be a written plan describing QAPI scope, objectives, organization, responsibilities, participants &amp; procedures </li></ul>
    • 13. V626 QAPI Condition Statement <ul><li>The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. </li></ul>
    • 14. V626 QAPI Condition Statement <ul><li>The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. </li></ul>
    • 15. Effective QAPI <ul><li>(V627) …an ongoing program that achieves : </li></ul><ul><li>Measurable improvement in health outcomes and </li></ul><ul><li>Reduction of medical errors </li></ul>
    • 16. Data-Driven QAPI <ul><li>(V627) Using indicators or performance measures associated with improved health outcomes and with identification and reduction of medical errors </li></ul>
    • 17. Operational Responsibility for QAPI <ul><li>Review Quality Indicators </li></ul><ul><li>Education of facility medical staff in QAPI objectives </li></ul><ul><li>Review method of prioritizing QI projects </li></ul><ul><li>Inclusion of all staff in QAPI </li></ul><ul><li>Communication with governing body </li></ul><ul><li>Participation in evaluation of effectiveness of QAPI </li></ul>
    • 18. &nbsp;
    • 19. QAPI: Facility-Based Assessment and Improvement of Care <ul><li>Compliance determined by </li></ul><ul><ul><li>Review of clinical outcomes </li></ul></ul><ul><ul><li>Data &amp; records of QAPI activities </li></ul></ul><ul><ul><li>Interviews of responsible staff including MD </li></ul></ul><ul><li>Failure </li></ul><ul><ul><li>Absence of an effective QAPI program </li></ul></ul><ul><ul><li>Failure to recognize &amp; prioritize major problems </li></ul></ul><ul><ul><li>Failure to take action to address identified problems </li></ul></ul>
    • 20. Content of QAPI <ul><li>Facility must measure, analyze and track quality indicators that reflect process of care &amp; facility operations – including (but not limited to) </li></ul><ul><li>Adequacy of dialysis </li></ul><ul><li>Nutritional status </li></ul><ul><li>Mineral metabolism &amp; renal bone disease </li></ul><ul><li>Anemia management </li></ul><ul><li>Vascular access </li></ul><ul><li>Medical injuries &amp; medical error identification </li></ul><ul><li>Hemodialyzer reuse program </li></ul><ul><li>Patient satisfaction and grievances </li></ul>
    • 21. Performance Measures (See MAT)  Fistula,  catheter rate (V633)Vascular access  Frequency of specific errors (V634) Medical errors  Infections,  vaccination status (V637) Infection control  Survey scores (V636) Pt satisfaction  Adverse outcomes V635) Reuse Hgb, Ferritin (V632) Anemia PTH, Ca+, Phos (V631) Bone disease Albumin, body weight (V630) Nutrition Kt/V, URR (V629) Adequacy
    • 22. V626 QAPI Condition Statement (cont.) <ul><li>The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team . </li></ul>
    • 23. Interdisciplinary Team: <ul><li>Show Me The Progress </li></ul>
    • 24. V626 QAPI Condition Statement (cont.) <ul><li>The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... </li></ul><ul><li>… The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS </li></ul>
    • 25. Monitoring Performance Improvement <ul><li>(V638) The facility must: </li></ul><ul><li>Continuously monitor its performance </li></ul><ul><li>Take actions that result in performance improvement </li></ul><ul><li>Track to assure improvements are sustained over time </li></ul>
    • 26. Prioritizing Improvement Activities <ul><li>(V639) Considerations in prioritization </li></ul><ul><li>Prevalence of problem </li></ul><ul><li>Severity of problem </li></ul><ul><li>Impact on clinical outcomes </li></ul><ul><li>Impact on patient safety </li></ul>
    • 27. Immediate Correction <ul><li>Examples of serious health and safety threats: </li></ul><ul><li>Unsafe water or dialysate </li></ul><ul><li>Defective clinical equipment </li></ul><ul><li>Unsafe reprocessing of dialyzers </li></ul><ul><li>Epidemiological risks </li></ul><ul><li>Insufficient number of competent staff to perform scheduled treatments: </li></ul><ul><ul><li>Preserve accesses </li></ul></ul><ul><ul><li>Monitor patients </li></ul></ul><ul><ul><li>Assure safe machine function </li></ul></ul>
    • 28. Measurement Assessment Tool (MAT) <ul><li>In using the MAT for individual patient assessments and plans of care, patient target levels should be assessed using the MAT. However, each patient should be treated individually and when a specified target is not met, either the plan of care should be adjusted to achieve the community-accepted standard or an explanation should be provided by the interdisciplinary team member of the group. Initially, goals for some patients may need to be different from these targets and then incrementally changed to the standard value as the patient outcomes improve. </li></ul>
    • 29. &nbsp;
    • 30. Set Priorities for Performance Improvement <ul><li>Incorporate CMS-generated data reports and facility-generated data </li></ul><ul><li>Prioritize </li></ul><ul><li>Rank those which have potential to affect patient health and safety </li></ul>
    • 31. Examples of Areas for Performance Improvement <ul><li>Dangerous levels of contaminants in product water </li></ul><ul><li>Unsafe levels of electrolytes in dialysate </li></ul><ul><li>Failure to provide adequate observation of patients, vascular access, patient equipment </li></ul><ul><li>Defective clinical equipment </li></ul><ul><li>Failure to adequately disinfect reprocessed dialyzers </li></ul><ul><li>Failure to reduce residual germicides in reprocessed dialyzers to safe levels </li></ul>
    • 32. Examples of Areas for Performance Improvement <ul><li>Lack of qualified staff to perform crucial tests or to meet critical patient needs </li></ul><ul><li>Evidence that staff assigned to perform crucial tests or meet critical patient needs are not competent </li></ul><ul><li>Potential for cross-contamination between infected and non-infected patients </li></ul><ul><li>Failure to use machine-provided safety devices (alarms, bypassing air detectors, etc) </li></ul>
    • 33. Dialysis Chains: Top Patient Safety Issues <ul><li>Patient Falls </li></ul><ul><li>Medication Errors </li></ul><ul><li>Access-Related Events </li></ul><ul><li>Dialyzer Errors </li></ul><ul><li>Excess blood loss and prolonged bleeding </li></ul>
    • 34. RPA Patient Safety Surveys <ul><li>Medication errors recognized frequently by patients and staff </li></ul><ul><li>Patient Falls remain frequent source of adverse events </li></ul><ul><li>Handwashing is recognized as patient safety issue in dialysis units </li></ul><ul><li>Correct dialysis set-up and predialysis procedures are safety issues </li></ul><ul><li>Adherence to procedures is a major source of medical mistakes </li></ul>
    • 35. &nbsp;
    • 36. Patient and Staff Concern about Safety and Medical Mistakes <ul><li>Patients worry about medical mistakes more than they experience them (49%) </li></ul><ul><li>Most staff (87%) are aware that medical mistakes have occurred in past 3 months </li></ul>
    • 37. Keeping Kidney Patients Safe <ul><li>http://kidneypatientsafety.org/ </li></ul><ul><li>http://www.networkofnewengland.org/5Diamond.htm </li></ul><ul><li>http://www.esrdnet5.org/5Diamond.asp </li></ul>5 Diamond Patient Safety Program
    • 38. Summary: Medical Director Responsibilities for QAPI <ul><li>The medical director is responsible for a wide-ranging, robust QAPI program </li></ul><ul><li>There must be a multi-disciplinary team </li></ul><ul><li>There must be education of medical staff about the QAPI program </li></ul><ul><li>There must be a written plan, monthly meetings, data analysis, prioritization </li></ul><ul><li>There must be clear action taken in identified areas to improve quality and safety </li></ul>
    • 39. Summary: Medical Director Responsibilities for QAPI <ul><li>The plan must include at a minimum all of these areas </li></ul><ul><ul><li>Adequacy of dialysis </li></ul></ul><ul><ul><li>Nutritional status </li></ul></ul><ul><ul><li>Mineral metabolism &amp; renal bone disease </li></ul></ul><ul><ul><li>Anemia management </li></ul></ul><ul><ul><li>Vascular access </li></ul></ul><ul><ul><li>Medical injuries and medical error identification </li></ul></ul><ul><ul><li>Hemodialyzer reuse program </li></ul></ul><ul><ul><li>Patient satisfaction &amp; grievances </li></ul></ul>
    • 40. Summary: Medical Director Responsibilities for QAPI <ul><li>Compliance will be determined by </li></ul><ul><ul><li>Review of clinical outcomes </li></ul></ul><ul><ul><li>Review of QAPI team records </li></ul></ul><ul><ul><li>Interviews with responsible staff </li></ul></ul><ul><li>Failure will be determined by </li></ul><ul><ul><li>Absence of an effective QAPI program </li></ul></ul><ul><ul><li>Failure to recognize &amp; prioritize major problems </li></ul></ul><ul><ul><li>Failure to take action </li></ul></ul>
    • 41. Clicker Question!!! <ul><li>Who is responsible for a facility’s quality assurance and performance improvement program? </li></ul><ul><ul><li>The interdisciplinary team </li></ul></ul><ul><ul><li>The medical director </li></ul></ul><ul><ul><li>The governing body </li></ul></ul><ul><ul><li>All of the above </li></ul></ul>
    • 42. Friendly Surveyor Successful QAPI Uh Oh…. RAC

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