Increasing AVF Rates in Facilities with AVF Rates < 50%

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  • The main objective of the initiative is to:

    Have every eligible patient receive the most optimal form of vascular access – and that would be an AV fistula.
    An AV fistula is considered the gold standard in vascular access because it has the least complications, need less rework or repairs, are asscoiated with lower rates of infection, hospitalization and death, and lasts longer than AVGs and catheters.
    The 2006 KDOQI guidelines recommend that greater than  65%  of hemodialysis patients have a functioning AVF.

    To ensure every vascular access undergo appropriate monitoring and surveillance to avoid vascular access complications.
    The KDOQI guidelines, Guideline 4, lists the acceptable methods for monitoring and surveillance.





  • Although the majority of facilities and the Network in general is progressing towards CMS’s goal, we still have several facilities that do not meet at least the minimum 50% AVF rate.

  • Since majority of our facilities have basically reached a plateau in their AVF rates because all patients that are eligible for AVFs have them placed, within the last year or so, we have been encouraging facilities to concentrate on Change Concepts 6, 7, and 9 to further improve facility vascular access outcomes.

    Change concept #6 is Secondary AVF placement in patients with AV grafts.
    Change concept # 7 is AVF placement in patients with catheters where indicated.
    And…Change concept #9 is Monitoring and maintenance to ensure adequate access
    function.

    These elements should be considered as it applies to your facility.

    Example, if your facility has a > 24% of grafts then your facility should consider concentrating on Change Concept #6 as one of its focus.
  • Conduct site visits as necessary to verify implementation of QAPI plans or
    assist facilities with specific issues.

  • The MRB monitors all facilities with a < 50% AVF rate.
  • This graph shows the AVF percentile breakdown from August 2008 to May 2009.

    Facilities in this < 50% category need to find more creative ways of improving their vascular access outcomes.

    By conducting this project, we hope that you can learn what areas within your facility can be improved to increase your vascular access outcomes.
  • To achieve this, each facility must meet each of their goals – which is determined by applying the same quality deficit reduction formula that CMS uses to calculate the Networks AVF goal.

    The Network will provide each facility with their specific goals.

    The baseline AVF rate we will use for the project is the SIMS Vascular Access Rate for May 2009.

  • The QAPI will be due on November 2, 2009.
  • Conference call meetings will be scheduled for the last Wednesdays of the month to discuss issues, concerns, ask questions, etc.

    This will allow for open discussions and brainstorming that may be beneficial for all facilities.

    This will also allow you to evaluate your plans at least monthly and revise them as necessary with possible solutions/ideas from other facilities.

    Have a representative present at each call.
  • To conduct a root-cause analysis and develop a Quality Assessment and Performance Improvement Plan with your interdisciplinary team.
    The QAPI plan will be submitted to the NW
    Tracking and trending improvements
  • This is a condition level requirement.

    Interpretation of this requirement can be found under v-tag V626 in the Interpretive Guidelines.
    The Interpretive Guidelines along with the new Conditions for Coverage can be found
    on the Network 18 website.
  • During this project we will be focusing on vascular access outcomes.

    Vascular outcomes are the “data-driven” indicators and measures we will be looking at during this project.
  • Per the Interpretive Guidelines:
    Facility data should be analyzed by the interdisciplinary team on an ongoing basis.
    The facility must use broadly accepted, community-developed standards as
    performance measures (this could be the MAT tool and CMS/NW goals)
    The interdisciplinary team must work with inidvidual pateints who do not reach the
    targets and it must be reflected in the patient’s plan of care for that outcome.

    The facility should also track and trend data for improvement and sustainability of those improvements.
  • Per the Interpretive Guidelines:
    Tracking and trending, analysis of root causes, development of improvement plans,
    implementation of those plans, evaluation of the success of the plan, and revision of
    the plan must occur as indicated – which is basically re-measurement of your data for
    improvements.
    Once improvement is made, the facility must have a mechanism to ensure that
    improvements are sustained. This could be tracking and trending and having triggers
    to know when the facility needs to re-evaluate their plan or process.
  • One form of root cause analysis is using the fishbone diagram.

    The problem is written as the “head” of the fish skeleton.
    From there, the spines are all categories and specific causes that could contribute to
    the problem.
    With each specific cause, ask “Why” it is ocuring until you get
    to the bottom of the cause – in which you cannot ask “why” anymore.
    You can add as many spines on your fishbone diagram as needed.
  • Once you have determined a root cause. You then can develop your plan using the PDSA (Plan-Do-Study-Act) model.

    This model encompasses the elements of a QAPI plan as stated in the CfC requirements.
  • A PDSA template will be sent to the facility to help facilities develop their QAPI plan.

  • Elements under plan are:
    Setting your objective for the project
    What you are hoping to accomplish with this plan.

    Setting goals to achieve (determine numerical goals and a target date)
    For this project the goal will be to achieve an increase in prevalent AVF
    rate by at least 4 percentage points by May 2010.

    Developing your plan on how you will improve your identified problem
    Make sure you write the details your plan. List your activities/strategies
    step-by-step
    By writing out your plan step-by-step, you can easily go back
    to the specific activity or strategy that may not have worked
    and revise it.
    Please remember that you can only develop a plan for those issues you
    can control.

    List data sources you will use to monitor your progress for the project
    Examples of this is your facility-specific SIMS report from the
    Network, your internal facility vascular access logs, patient tracking
    logs, etc.

  • Write out the measure you will be using to analyze if you are achieving your goal.
    This is usually a numerical formula.



  • Note your baseline for comparison towards your goal and the frequency in
    which you will conduct measurement of your progress

    For this project we will be re-measuring monthly.
  • Step 2 – Do:
    Implement your plan.
    Note the problems you encounter and other findings. By noting these you can
    review your plan and determine what changes can be or needs to be made to your
    plan.

    Step 3 – Study:
    Using your data sources, analyze the results of your plan with your interdisciplinary
    team. Are you progressing towards your goal?
    Track and trend your progress. This way it will be easy to visually see if you are
    moving towards your goal.
    If you are not progressing towards the goal, revise your plan as necessary to achieve
    the goal – think of new strategies.

  • And Step 4 – Act:

    This step assess if your plan is successful – Are you moving towards your goal or have you already achieved your goal.

    If you are successful, how will you ensure continued improvement?
    - The facility can monitor improvements to ensure sustainability, develop a process
    or policies & procedures, etc.

    If it wasn’t successful – what needs to be changed base on what you have learned.
    - Should you continue looking for other root causes?
  • In conducting a root cause analysis of Network 18 facilities’ possible obstacles and barriers based on previous projects and communication with the community, majority of the obstacles can be summarized under 3 categories:

    Education
    Process
    Communication


  • Some examples of possible solutions to these issues as learned from other facilities or suggested by the FFBI.

    To learn other possible strategies or solutions for issues is to discuss them with other facilities. At the least, you can brainstorm with these other facilities to find solutions for your issues or common issues together.


  • This letter is designed for nephrologists to communicate with Primary Care Physicians or Insurance companies regarding early referral for CKD patients.
  • Most areas have at least one surgeon available to serve the ESRD patient population. Education and communication with these surgeons can possibly make a difference.

    When available, inform your surgeons of surgical symposiums or conferences - encourage them to attend.
  • Encourage your surgeons to attend these meetings - have them speak with their colleagues in those counties to find out when these meetings are scheduled.
  • Under this Change Concept:
    Nephrologists should communicate expectations to surgeons regarding AVF
    placement and training in current AVF surgical techniques, based on KDOQI
    Guidelines and best practices.
    Nephrologists should refer to surgeons willing and able to meet AVF expectations
    based on KDOQI and best practices.
    Surgeons should be continuously evaluated on frequency, quality, and patency
    of access placements.
    The surgeons outcomes can be tracked at the facility level and should be
    incorporated in your vascular access program.

  • Stress the importance of continuity of care for our patients.
  • Education plays a big role in engagement of nephrologists and surgeons. They must understand the importance of vascular access care for our patient population.
  • Involve them in your QAPI meetings.

    Share your facility’s vascular access data with them.

    Encourage them to find out about access club meetings, surgical conferences, etc.
  • It is under the control of the individual nephrologist to see to it that his/her patient(s) have quality vascular access care.
    This would include having vein mapping done to evaluate and verify if a patient is a
    candidate for an AVF.
  • Nephrologists should refer to surgeons willing and able to meet AVF expectations based on KDOQI and best practices.


  • The first thing we should find out about these patients are if they are a candidate for and AV fistula. Have they been referred for an evaluation?

    If they are a candidate, most of these issues stem from lack of education about vascular access. The key for these patients are education and repetition.

    Even though you educate these patients and they refuse, periodically discuss vascular access with them always stressing the benefits of an AV fistula. Make sure you document your education and/or discussions with the patient on the patient’s plan of care.

  • Education materials have been distributed to your facilities throughout the years. You can also find other patient resources on the Fistula First website.

    Do not just had these materials to the patients and or their families, sit down with them and discuss it.
  • When the staff is knowledgeable about vascular access care, they can easily talk to patients about it.

    Involve Social Workers with teaching staff how to teach and communicate with patients.




  • The Medical Director Acknowledgement Letter was addressed and mailed to the Medical Director. Please remind him/her to sign and return this letter.
    Next week you will receive a Toolkit for this project. In the toolkit will be resources and templates for the QAPI plan.
    The QAPI plan is in the PDSA format.
    Develop your plan with your interdisciplinary team
    Have your Medical Director sign the plan before you submit it. The reason we are asking the Medical Director to sign the plan is because he/she is responsible for the QAPI program at your facility.
    The QAP plan is due on Monday, November 2nd

  • Your facilities should have provided a contact person and e-mail address in your environmental scan.

    If there are any changes to this please notify me with the current or correct information.

    In the past, we have had e-mail delivery problems with facility firewalls, please ensure that you are able to receive e-mails from me so that you will not miss any information about the project. Consult with your IT department to assist you with this.
  • Increasing AVF Rates in Facilities with AVF Rates &lt; 50%

    1. 1. Increasing AVF Rates in Facilities with AVF Rates < 50% Project Lisle Mukai, QI Coordinator ESRD Network 18 September 30, 2009
    2. 2. Special Acknowledgement for Slide Content Contribution: • Fistula First Breakthrough Initiative Website • Mid-Atlantic Renal Coalition (FFBI: Presentation to CMS/ESRD-Annual Meeting) • CMS Surveyor Training (Condition: Quality Assessment and Performance Improvement - Show Me The Progress
    3. 3. Fistula First Breakthrough Initiative (FFBI)  The FFBI is a collaboration between the Centers for Medicare and Medicaid Services (CMS), ESRD Networks, and the renal community.  Began in 2003  Main objective: 1. To have every eligible patient receive the most optimal form of vascular access-AVF 2. To ensure every vascular access undergo appropriate monitoring and surveillance to avoid vascular access complications.
    4. 4. Fistula First AVF Goals  CMS Prevalent AVF Goal = 66% Network 18 2009-2010 AVF Goal:  Network 18 Goal = 57.8%  Network 18 Stretch Goal = 58% Current AVF Rates:  National: 53.2% (July 2009)  Network 18: 56.9% (July 2009)
    5. 5. Tools & Best Practices: Fistula First Change Concepts 1. Routine CQI Review of vascular access 2. Timely referral to nephrologist 3. Early referral to surgeon for “AVF Only” 4. Surgeon Selection 5. Full range of appropriate surgical approaches 6. Secondary AVFs in AVG patients 7. AVF evaluation/ placement in catheter pts 8. Cannulation training 9. Monitoring and maintenance 10. Continuing Education 11. Outcomes feedback
    6. 6. Cost Per Patient by Access Type (USRDS 2006 data) Annual Per Patient Per Year Expenditure  Catheter $77,093  Graft $71,616  AVF $59,470 The annual per patient cost savings of an AVF over a graft is $12,269 The annual per patient cost savings of an AVF over a catheter is $17,746
    7. 7. Network 18 activities to promote & support Fistula First  Monthly data collection ◦ Electronically by LDOs (DaVita & FMC) ◦ Manual submission by Independent & SDOs.  Distribute quarterly feedback reports (Facility-specific reports, SIMS reports, and Network summary reports)  Sharing best practices via Fistula First Newsletter
    8. 8. Network 18 activities to promote & support Fistula First (continued)  Provide current educational information relevant to professionals and patients on the NW 18 website and mailings.  Work with the MRB to develop projects to assist identified facilities in improving outcomes.  Site visits
    9. 9. Increasing AVF Rates in Facilities with AVF Rates < 50% Project  Facilities > 50% AVF Rate = 73.1% (198 facilities – as of May 2009) 108 facilities = 50-59% 67 facilities = 60-69% 23 facilities = > 70%  Facilities < 50% AVF Rate = 26.9% (73 facilities – as of May 2009)
    10. 10. 0 20 40 60 80 100 120 140 < 50% 50-59% 60-69% 70-79% > 80% NumberofFacilities Network 18 AVF Percentile Breakdown Aug-08 Sept-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09
    11. 11. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued) Inclusion Criteria for the project: o AVF rate < 50% (May 2009 SIMS data) o Patient census > 50 patients Exclusion Criteria: o Patient census < 50 patients o Facilities already included in another QIWP Project (exception of SMR and Clinical Indicator Goals Project) o Facilities participating in Phase 2 of CROWNWeb
    12. 12. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued)  Objective: ◦ To have each participating facility review their vascular access program and determine root cause(s) for their facility’s low AVF rate. ◦ Each facility will develop a Quality Assessment and Performance Improvement Plan to improve their AVF rate based on their root cause analysis ◦ Implement their plan and revise their plan along the way by making necessary changes if certain strategies/activities are not successful. ◦ Develop a process to sustain improvements.
    13. 13. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued)  Goal: Group Goal: The participating group of facilities will achieve an increase in the prevalent AVF rate by at least 4 percentage points by May 2010 Facility Goal: Determined by applying the CMS quality deficit reduction formula 66%-AVF rate x 20% = expected improvement AVF rate + expected improvement = goal
    14. 14. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued)  Timeline: Project period: September 2009 to May 2010  Due dates: ◦ Facility Manager Acknowledgement Letter – August 26, 2009 ◦ Environmental Scan – August 26, 2009 ◦ Medical Director Acknowledgement Letter – September 9, 2009 ◦ Quality Assessment and Performance Improvement Plan (PDSA: Plan-Do-Study-Act format) – November 2, 2009
    15. 15. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued)  Conference Calls Monthly calls to share and discuss successes and issues. ◦ Very important because it gives each facility the chance to discuss their concerns or share their issues with others and possibly find solutions to problems.  Last Wednesdays of the month starting on October 28, 2009 at 2pm.
    16. 16. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued)  Network Responsibilities: ◦ Project Leader ◦ Instruct/assist with the QI process ◦ Distribute templates for RCA and PDSA ◦ Distribute toolkits/resources and evaluate their usefulness
    17. 17. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued) Network Responsibilities (continued) ◦ Provide monthly feedback reports (SIMS) ◦ Facilitate monthly conference calls ◦ Provide technical assistance as necessary ◦ Conduct facility site visits as necessary
    18. 18. Increasing AVF Rates in Facilities with AVF Rates < 50% Project Facility Responsibility:  Conduct a root-cause analysis and develop a Quality Assessment and Performance Improvement Plan  Submit your QAPI plan  Implement QAPI plan and revise as necessary during the project  Monitor your facility’s progress towards achieving the goal
    19. 19. Increasing AVF Rates in Facilities with AVF Rates < 50% Project (continued) Facility Responsibility (continued):  Identify tools that would be useful for your facility  Participate in monthly conference calls  Follow project timelines/due dates  Submitting requested documents for the project in a timely manner
    20. 20. Quality Assessment and Performance Improvement Plan (QAPI) 494.110: (V626) Condition 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.
    21. 21. Quality Assessment and Performance Improvement Plan (QAPI)  Interdisciplinary Team: (minimum) o Physician o Registered nurse o Social Worker o Dietitian  Also include your surgeon(s) and interventional radiologist(s)
    22. 22. Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Program Scope: 1. The program must include, but not limited to, an ongoing program that achieves measurable improvement in healthcare outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.
    23. 23. Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Program Scope: 2. The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations.
    24. 24. Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Monitoring performance improvement: The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.
    25. 25. Quality Improvement Process Root Cause Analysis: Finding the real cause of the problem and dealing with it rather than simply dealing with the symptoms. o Those situations which are recurring with the greatest frequency and consume the greatest amount of resources to rectify are candidates for RCA o To find the root cause, ask “Why?” until the pattern completes and the cause of the difficulty in the situation becomes rather obvious. Gene Bellinger 2004
    26. 26. Quality Improvement Process: Plan-Do-Study-Act: PDSA is the format the Network uses for developing a QAPI plan. ACT PLAN STUDY DO
    27. 27. Adopted from IHI Website, June 2007 PROJECT: TEAM: (List all members) BACKGROUND: (Summary of facility’s identified problem and description of what the facility has been doing to improve the problem.) Step 1. PLAN: Plan the test. What is the objective of this improvement cycle? What is the goal? (Include a numeric goal to achieve.) Develop a plan to achieve the goal? (List steps of the plan – this will allow you to identify the step that may need modifying/revising if necessary.) 2 of 3 pages What data sources are needed for the test? (What data sources will you be using to monitor your progress?) What measures are used to analyze if you are achieving the goal? BASELINE: Measure: (Numerical formula) Monitoring frequency: PDSA Template
    28. 28. Step 2. DO: Try out the test on a small scale. Implement the plan. Document problems and unexpected observations. Step 3. STUDY: Set aside time to analyze the data and study the results. Analyze the results and compare the results with your goal. Step 4. ACT: Determine if the test was successful or the plan needs to be revised. If the test was successful, how will you implement the plan on a wider scale? If it was not successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes?
    29. 29. Plan-Do-Study-Act (PDSA)  Plan:  Set your objective for the project  Set goals to achieve (numerical goals and a target date)  Develop your plan on how you will improve your identified problem  List data sources you will use to monitor your progress for the project
    30. 30. Plan-Do-Study-Act (PDSA) (continued) Plan (continued):  Write out the measure you will be using to analyze if you are achieving your goal. (numerical formula) # of prevalent patients using AVF as primary access Total # of patients at the facility
    31. 31. Plan-Do-Study-Act (PDSA) (continued) Plan (continued):  Note your baseline for comparison towards your goal  Note the frequency in which you will conduct measurement of your progress
    32. 32. Plan-Do-Study-Act (PDSA) (continued) Plan (continued): When you develop your plan, write out your methodology (what you are going to do step-by-step). This way when you implement your plan you can go back to the step that may not have worked and revise it.
    33. 33. Plan-Do-Study-Act (PDSA) (continued) Do:  Implement your plan  Document problems and unexpected observations of your plan Study:  Analyze the results and compare it to the goal  This analysis should be conducted with the interdisciplinary team.  Revise plan if necessary to achieve goal
    34. 34. Plan-Do-Study-Act (PDSA) (continued) Act:  Is your plan successful?  How will you ensure continued improvement?  If it wasn’t successful, what needs to be changed based on what you have learned?  Should you continue to search for other root causes?
    35. 35. Plan-Do-Study-Act (PDSA) (continued)  The PDSA cycle is a continuous cycle. It allows you to frequently assess your plan and make revisions as necessary to achieve your goal.  Your plan should be reviewed at least monthly and/or when you realize that your strategy or activity is not working.
    36. 36. Plan-Do-Study-Act (PDSA) (continued)  You can go back to any step and revise as necessary.  Note your progress on your form so that you have a record of the strategies/activities you’ve attempted and results of those attempts as well as the revisions you have made to improve your plan.
    37. 37. Overcoming Obstacles and Barriers Categories for Network 18 facilities’ common obstacles and barriers:  Education  Process  Communication
    38. 38. Overcoming Obstacles and Barriers (continued) Insurance: Communication:  When you send a patient to the surgeon for de- clotting of an AVG or catheter send a letter to that surgeon explaining all the difficulties and frequency of those difficulties you have had with that access and why you would like that patient evaluated for an AVF. When the problem occurs frequently, it is justifiable for the surgeon to recommend and place another access.
    39. 39. Overcoming Obstacles and Barriers (continued)  Fistula First has a “Payer Packet” (Found on Fistula First website) Includes: o Flyer explaining about the Fistula First Breakthrough Initiative, why this program matters, and what the insurance company can do. o Summary of Recommendations o FFBI Priority Recommendations o Graphs/charts on vascular access costs
    40. 40. Overcoming Obstacles and Barriers (continued)  Fistula First Sample Letter for PCP or Insurance companies (Found on the Fistula First website)  Encourage patients to become an advocate for their care. Involve SW to assist patient on what to discuss with the insurance company.
    41. 41. Overcoming Obstacles and Barriers (continued) No surgeons/good surgeons in the area: Education:  Nephrologists and the facility (Medical Director, Manager or Vascular Access Coordinator) speak with surgeons about the Fistula First program and the facility’s expectation of the surgeon to meet goals of the Fistula First program.  Refer surgeons to the Fistula First website for resources including the surgical video “Creating AV Fistulae in All Eligible Hemodialysis Patients”
    42. 42. Overcoming Obstacles and Barriers (continued) Education (continued):  Share the Cannulation DVD with the surgeons so that they understand the logistics of cannulation and can position the veins suitably and safely for cannulation. Communication:  If facilities in the same area use the same surgeon(s), all facilities should communicate the same message/urgency regarding AVF placement.
    43. 43. Overcoming Obstacles and Barriers (continued) Communication (continued):  The San Diego and Orange County areas have Dialysis Access Club meetings in which any surgeons, interventional radiologist, nephrologists, and dialysis staff can attend. These meetings are a great open discussion forum for issues in accesses creation, complications, etc. that these disciplines can discuss.  Nephrologists can discuss with their colleagues about which surgeons they utilize and how well those surgeons perform.
    44. 44. Overcoming Obstacles and Barriers (continued) Process:  If you have access to a Vascular Access Center, use those facilities for AVF evaluations - vein mapping – and communicate results with surgeons. You can also use the centers for follow-up after an AVF placement to ensure the access is maturing.  Implement Change Concept #4: Surgeon selection based on best outcomes, willingness, and ability to provide access services.
    45. 45. Overcoming Obstacles and Barriers (continued) No communication/relationship between Nephrologist and Surgeon: Communication:  Try and convey to these physicians and surgeons that the ultimate concern is the patient’s well being.  Involve Regional Managers and/or Medical Directors to talk with them and convey the facility’s goals and expectations.
    46. 46. Overcoming Obstacles and Barriers (continued) Communication (continued):  Invite the surgeon to the facility to get a first hand look at dialysis and what impact they have on the patient’s care and treatment.  Facilities develop a communication process with the surgeon’s office – Nephrologist/facility staff meet with the surgeon and explain the Fistula First program, facility expectations and have an agreement with the surgeon to communicate patient progress/status with the facility.
    47. 47. Overcoming Obstacles and Barriers (continued) Nephrologists or Surgeons Not Engaged: Education:  Educate nephrologists and surgeons about the Fistula First Program – set up a meeting in which you can discuss the program and the facility’s goals and expectations.  Refer or download resources from the Fistula First website for nephrologists and/or surgeon.
    48. 48. Overcoming Obstacles and Barriers (continued) Communication (continued):  Find ways to engage your surgeons and nephrologists (i.e. Share your facility specific data that you receive from the Network, inform them about the vascular access clubs, etc.).
    49. 49. Overcoming Obstacles and Barriers (continued) Nephrologist or facility has no control over what access is placed. It is under the control of the individual nephrologist to see to it that his/her patient(s) have quality vascular access care. Communication:  Inform surgeon of access preference.  A sample letter to surgeons is available on the Fistula First website.
    50. 50. Overcoming Obstacles and Barriers (continued) Communication (continued):  Have the nephrologist consult with other nephrologists/surgeons on who they can refer their patients if the current surgeon is not engaged in the Fistula First program or does not perform well.
    51. 51. Overcoming Obstacles and Barriers (continued) Patient refuses AVF placement, patient is scared, patient is comfortable with current access, patient refuses another surgery, patients access is still functioning, etc.: Education:  Educate the patient as a team. If the patient hears the same message from different disciplines, they are more likely to believe that it is for their best interest and comply.
    52. 52. Overcoming Obstacles and Barriers (continued) Education (continued):  Multiple patient education materials can be found on the Fistula First website.  Review materials and resources with the patients/families as it applies to the patient.  Encourage family support
    53. 53. Overcoming Obstacles and Barriers (continued) Education (continued):  Designate a Vascular Access Coordinator to educate and work with these patients and have the team support his/her teaching by reiterating the same message.  Facilities should conduct an in-service regarding vascular access (benefits, assessment, care, and how to teach/communicate it with the patients  Involve Social Workers with teaching staff how to teach/communicate with patients.
    54. 54. Project Summary and Expectations:  Develop a Quality Assessment and Performance Improvement Plan and submit a copy to the Network (Due: November 2, 2009)  Implement QAPI plan and revise as necessary during the project  Monitor your facility’s progress towards achieving the goal  Participate in monthly conference calls Scheduled for the last Wednesdays of the month at 2pm
    55. 55. Project Summary and Expectations:  Follow project timelines/due dates  Submit requested documents  Facility Manager Acknowledgement Letter (Due: August 26, 2009)  Environmental Scan (Due: August 26, 2009)  Medical Director Acknowledgement Letter (Due: September 9, 2009)  QAPI Plan – Signed by the Medical Director (Due: November 2, 2009)  Other requested documents during the project
    56. 56. Resources  Fistula First www.fistulafirst.org  Network 18 www.esrdnetwork18.org The toolkit with resources will be mailed to your facilities next week. Please review them and use them as they pertain to your facility.
    57. 57. Project Communication:  To communicate more efficiently with you about this project and to be more eco- friendly, we are creating a listserv of all the facilities in this project.  In the past, we have had e-mail delivery problems with facility firewalls, please ensure you are able to receive e-mails from me about the project.  Consult with your IT Department to assist you.
    58. 58. Lisle Mukai, RN Quality Improvement Coordinator ESRD Network 18 323-962-2020 lmukai@nw18.esrd.net

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