Quality Improvement Overview

The primary goal of the ESRD Network is to improve the quality of health care services provided to ESRD beneficiaries. Network 4 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 from the Network Quality Improvement (QI) staff and Medical Review Board (MRB), and the provision of educational opportunities, materials and resources.

Areas in need of improvement in Network 4 are identified by:

CMS direction
Patient and facility communications
Various data collections (Fistula First, Dialysis Facility Report, CPM Annual Report, Lab Data Collection)
State surveyor and Quality Improvement Collaborations (QIO)

Quality Initiatives may be done through general measures for all facilities, such as the distribution of educational materials, or by focused Network activities with specific facilities. The Medical Review Board has developed Quality Initiatives in the areas of:

Improvement of AF fistula rates
Reduction of Catheter usage
Stenosis Monitoring
Phosphorus Control

Network 4 encourages each facility to participate in Network CQI activities, as well as establish their own continuous quality improvement program to:

Identify facility-specific processes and outcomes needing improvement
Idedntify root cause of problems
Develop and implement activities to correct problems
Evaluate effectiveness of activities

With the release of the Conditions for Coverage, the expectation is that facilities develop an internal Quality Assessment and Performance Improvement (QAPI) to promote continuous improvement and optimal outcomes.

§494.110 Condition: Quality Assessment and Performance Improvement
V626 - The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided by arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement program for review by CMS.

Quality of care issues to be addressed must include, but not be limited to the following:

Dialysis adequacy
Nutritional status
Anemia management
Vascular access
Bone disease management
Infection control issues
Medical injuries and medical errors identification
Vaccinations
Patient Education
Physical and mental functioning
Patient survival

What is Continuous Quality Improvement?

The purpose of any health care quality program must be to improve care and service. This statement sounds logical and obvious, yet it is amazing to see how far off the track some programs have veered. Facilities review records, revise documentation forms, log reports. But how often can we say that we have actually improved the care or service? Quality Assurance and Quality Improvement have given us good tools to assess, assure, or improve quality, yet we need to go further in tailoring them to create the greatest impact (change) at the clinical level.

What do I need to do to get started?

Clinical Peformance Goals 2010-2011 Document (format: PDF, size: 1.0 mb)
[Distributed July 2010] This document may be used to develop appropriate Quality Assessment and Performance Improvement (QAPI) programs within your unit.
Let us know what you think about our Clinical Performance Goals Document -- Evaluate online
NKF-K/DOQI Guidelines
Part 494 - Conditions for Coverage for ESRD Facilities

Find out where you are

Look at your data, displayed over time
Identify areas for improvement
Identify causes for poor results

Implement the Rapid Cycle Approach

The Rapid Cycle Improvement approach is an improvement process that relies heavily on an action plan, and works on a rapid trial and learns method. The process dramatically shortens the discovery process and Utilizes existing knowledge.

Steps for a Rapid Model of improvement: PLAN → DO → CHECK → ACT

PLAN: Develop new or improved processes that will fix identified problems
DO: Implement the new process in a limited pilot study
CHECK: Evaluate the results
ACT: Based on the evaluation, make necessary changes and then implement unit-wide

Quality Improvement Resources

Quality Improvement Plan Template (format: PDF, size: 125 kb) -- Use this template to list your problem, causes, barriers, team members, and track your tasks
Fishbone Diagram (format: PDF, size: 37 kb)
Instructions for Completing a Fishbone Diagram (format: PDF, size: 41 kb)

Immunization Resources

Network brochure: Why Do I Need the Influenza Shot: Facts to help you fight the flu (format: PDF, size: 420 kb) -- Taken from the "Safe and Timely Immunizations Coalition" [STIC] Resource Guide
Units in Pennsylvania -- You can also find materials on the Quality Insights of Pennsylvania, a Quality Improvement Organization (QIO)
Units in Delaware -- You can also find materials on the Quality Insights of Delaware, a Quality Improvement Organization (QIO)

Technical Assistance Available

ESRD Network 4 is happy to provide the following services ...

Provide education and assistance regarding CMS/Network directed QI projects
Assist facilities with developing internal CQI programs and action plans
Clarify instructions for completing CPM / clinical data collection forms
Assist facilities to develop emergency preparedness plans and patient/staff education
Provide vascular access expertise and education on cannulation including buttonhole
Consult with facilities regarding water quality and water treatment issues
Analyzes data on national, regional and local patterns of care for QI planning
Provide education and assistance regarding CMS requirements
Communicate essential information that will affect facilities via mail, e-bulletin, or fax
Represent the needs of the renal community, patients and providers to CMS
Develop collaborative partnerships to promote improved quality outcomes for patients
Inform facilities about Network goals and activities