The State Of E In Sexas
dialysis_pros
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127 slides
Oct 01, 2009
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About This Presentation
ESRD Network of Texas, Inc. Annual Educational Collaborative for ESRD professionals.
Presentations from the 2009 Annual Meeting
Slide Content
2009 ESRD Network of Texas, Inc. 2009 ESRD Network of Texas, Inc.
Network Coordinating Council Network Coordinating Council
Meeting Meeting
Network Coordinating Council Network Coordinating Council
Meeting Meeting
CHAIRMAN’S REPORT CHAIRMAN’S REPORT
RichardGibney MD RichardGibney MD Richard
Gibney
,
MD Richard
Gibney
,
MD
Network Network
Elections Elections
„ „
Network
Network
Elections Elections
„ „
QualityImprovement QualityImprovement
„ „
Quality
Improvement
Quality
Improvement
„ „
A A
PausetoReflect PausetoReflect
„ „
A
A
Pause
to
Reflect Pause
to
Reflect
Supporting Quality Care
RichardGibney MD RichardGibney MD Richard
Gibney
,
MD Richard
Gibney
,
MD
Network Network
Elections Elections
„ „
Network
Network
Elections Elections
„ „
QualityImprovement QualityImprovement
„ „
Quality
Improvement
Quality
Improvement
„ „
A A
PausetoReflect PausetoReflect
„ „
A
A
Pause
to
Reflect Pause
to
Reflect
Supporting Quality Care
NOMINATING NOMINATING
COMMITTEE09 COMMITTEE09
1010
NOMINATING
NOMINATING
COMMITTEE
09 COMMITTEE
09
--
10 10
„ „
Melvin Laski, Lubbock Melvin Laski, Lubbock Richard Richard
Gibney MD Waco Gibney MD Waco
„ „
Richard
Richard
Gibney
,
MD
,
Waco Gibney
,
MD
,
Waco
„ „
Robert Hootkins, Robert Hootkins, MD, MD, Austin Austin
„ „
Cleve Collins, MD, San Antonio Cleve Collins, MD, San Antonio Tom Tom
Lowery MD Tyler Lowery MD Tyler
„ „
Tom
Tom
Lowery
,
MD
,
Tyler Lowery
,
MD
,
Tyler
COMMITTEE09 COMMITTEE09
1010
NOMINATING
NOMINATING
COMMITTEE
09 COMMITTEE
09
--
10 10
„ „
Melvin Laski, Lubbock Melvin Laski, Lubbock Richard Richard
Gibney MD Waco Gibney MD Waco
„ „
Richard
Richard
Gibney
,
MD
,
Waco Gibney
,
MD
,
Waco
„ „
Robert Hootkins, Robert Hootkins, MD, MD, Austin Austin
„ „
Cleve Collins, MD, San Antonio Cleve Collins, MD, San Antonio Tom Tom
Lowery MD Tyler Lowery MD Tyler
„ „
Tom
Tom
Lowery
,
MD
,
Tyler Lowery
,
MD
,
Tyler
Slate of Officers
Melvin Laski, MD, Chairman Melvin Laski, MD, Chairman
Manny Alvarez, MD, Vice Chairman Manny Alvarez, MD, Vice Chairman
Larry McGowan, Treasurer Larry McGowan, Treasurer
Amy Hackney, Secretary Amy Hackney, Secretary
Richard Gibney, MD Richard Gibney, MD
Immediate Past Chairman Immediate Past Chairman
RubenVelez MD MRBChair RubenVelez MD MRBChair Ruben
Velez
,
MD
,
MRB
Chair Ruben
Velez
,
MD
,
MRB
Chair
Laura Yates, RN, Laura Yates, RN, At Large At Large CharlesOrji,MD,AtLarge CharlesOrji,MD,AtLarge Charles
Orji,
MD,
At
Large Charles
Orji,
MD,
At
Large
Leigh Anne Tanzenburger, At Large Leigh Anne Tanzenburger, At Large
09 09--10 10 EXECUTIVE COMMITTEE EXECUTIVE COMMITTEE
Melvin Laski, MD, Chairman Melvin Laski, MD, Chairman
Manny Alvarez, MD, Vice Chairman Manny Alvarez, MD, Vice Chairman
Larry McGowan, Treasurer Larry McGowan, Treasurer
Amy Hackney, Secretary Amy Hackney, Secretary
Richard Gibney, MD Richard Gibney, MD
Immediate Past Chairman Immediate Past Chairman
RubenVelez MD MRBChair RubenVelez MD MRBChair Ruben
Velez
,
MD
,
MRB
Chair Ruben
Velez
,
MD
,
MRB
Chair
Laura Yates, RN, Laura Yates, RN, At Large At Large CharlesOrji,MD,AtLarge CharlesOrji,MD,AtLarge Charles
Orji,
MD,
At
Large Charles
Orji,
MD,
At
Large
Leigh Anne Tanzenburger, At Large Leigh Anne Tanzenburger, At Large
09 09--10 10 EXECUTIVE COMMITTEE EXECUTIVE COMMITTEE
Net okCoodinatingCo ncil Net okCoodinatingCo ncil Net
w
o
r
k
Coo
r
dinating
Co
u
ncil
Net
w
o
r
k
Coo
r
dinating
Co
u
ncil
Election Election
w
o
r
k
Coo
r
dinating
Co
u
ncil
Net
w
o
r
k
Coo
r
dinating
Co
u
ncil
Election Election
Words on Quality Words on Quality
Q
UALITY IMPROVEMENT
Q
„
URGENCY TO CHANGE:
„
Improve quality of care (
↓
harm)
„
Improve
quality
of
care
(
↓
harm)
.
All / Patients & family benefit
Win \ Staff (RN, PCT, SW, Dietitian, Physician
„
↓Mortality, improve quality indicators.
„
Evidence based medicine
,
best
p
ractices
,
more efficient time
,
,p , ,
patient flow.
„
↓Chance of liability.
„
Our reputation (not national average or less).
„
Transparency good! It i bl & lifti t b th b t t h l i f ll
„
It
is no
bl
e
&
up
lifti
ng
t
o
b
e
th
e
b
es
t
a
t
h
e
lp
ing our
f
e
ll
ow man.
UALITY IMPROVEMENT
Q
„
URGENCY TO CHANGE:
„
Improve quality of care (
↓
harm)
„
Improve
quality
of
care
(
↓
harm)
.
All / Patients & family benefit
Win \ Staff (RN, PCT, SW, Dietitian, Physician
„
↓Mortality, improve quality indicators.
„
Evidence based medicine
,
best
p
ractices
,
more efficient time
,
,p , ,
patient flow.
„
↓Chance of liability.
„
Our reputation (not national average or less).
„
Transparency good! It i bl & lifti t b th b t t h l i f ll
„
It
is no
bl
e
&
up
lifti
ng
t
o
b
e
th
e
b
es
t
a
t
h
e
lp
ing our
f
e
ll
ow man.
Q
UALITY IMPROVEMENT
Q
“
The
p
roblem with life is
,
p,
there is no SCARY music.” -- Robin Williams ↓Mortality, ↓Patients Harmed.
UALITY IMPROVEMENT
Q
“
The
p
roblem with life is
,
p,
there is no SCARY music.” -- Robin Williams ↓Mortality, ↓Patients Harmed.
Q
UALITY IMPROVEMENT
Q
„
DATA USE:
„
Right things easy \ BIG GOALS!
Bad things hard /
„
Simple & visual. Nd it
„
N
o
d
enom
ina
t
or.
„
“Hope is not a strategy.”
„
“Complexity is the enemy of reliability.” Protocols processes systems flow (orders diagnosis
„
Protocols
,
processes
,
systems
flow
(orders
,
diagnosis
,
& treatment.)
UALITY IMPROVEMENT
Q
„
DATA USE:
„
Right things easy \ BIG GOALS!
Bad things hard /
„
Simple & visual. Nd it
„
N
o
d
enom
ina
t
or.
„
“Hope is not a strategy.”
„
“Complexity is the enemy of reliability.” Protocols processes systems flow (orders diagnosis
„
Protocols
,
processes
,
systems
flow
(orders
,
diagnosis
,
& treatment.)
WE HAVE BEEN CALLED TO A MINISTRY,
WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON
’
S LIFE
WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON
’
S LIFE
;
A REAL AND TREASURED PRIVILEGE.
-- James Reinertsen, M.D.
September, 2008
WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON
’
S LIFE
WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON
’
S LIFE
;
A REAL AND TREASURED PRIVILEGE.
-- James Reinertsen, M.D.
September, 2008
LOAVES AND FISHES
This is not the age of This is not the age of information.
This is not
the age of information.
For
g
et the news
,
g,
and the radio,
and the blurred screen.
This is the time of loaves and fishes. People are hungry, and one
g
ood word is bread
g
for a thousand.
--
David Whyte
This is not the age of This is not the age of information.
This is not
the age of information.
For
g
et the news
,
g,
and the radio,
and the blurred screen.
This is the time of loaves and fishes. People are hungry, and one
g
ood word is bread
g
for a thousand.
--
David Whyte
Report from the Executive Report from the Executive
Director Director Director Director
Glenda Harbert, RN, CNN, CPHQ Glenda Harbert, RN, CNN, CPHQ
Director Director Director Director
Glenda Harbert, RN, CNN, CPHQ Glenda Harbert, RN, CNN, CPHQ
MISSION Statement MISSION Statement
The ESRD Network of Texas, Inc. The ESRD Network of Texas, Inc. supports quality dialysis & kidney t l t h lth th h ti t t
ransp
lan
t h
ea
lth
care
th
rou
gh
pa
ti
en
t
services, education,
q
ualit
y
qy
improvement & data exchange.
2003 2003
The ESRD Network of Texas, Inc. The ESRD Network of Texas, Inc. supports quality dialysis & kidney t l t h lth th h ti t t
ransp
lan
t h
ea
lth
care
th
rou
gh
pa
ti
en
t
services, education,
q
ualit
y
qy
improvement & data exchange.
2003 2003
Topics Topics
„
DSHS Referrals & Rules
„
NetworkGrowth
„
Network
Growth
„
Network Activities
„
DSHS Referrals & Rules
„
NetworkGrowth
„
Network
Growth
„
Network Activities
DSHSESRDLicensureRulesRevision DSHSESRDLicensureRulesRevision DSHS
ESRD
Licensure
Rules
Revision
DSHS
ESRD
Licensure
Rules
Revision
„
3 Stakeholder meetings
„
October & December 08, January 09
„
April 1 Submit rule packet to Office of
General Counsel by
„
June 25 ESRD rules will be proposed at the
DSHSC il ti DSHS
C
ounc
il
mee
ti
n
g
on
„
30 day comment period after the proposed
lblihd
ru
les are pu
bli
s
h
e
d
„
No decision yet if a public comment hearing willbeheldduringthe30daycommentperiod will
be
held
during
the
30
day
comment
period
ESRD
Licensure
Rules
Revision
DSHS
ESRD
Licensure
Rules
Revision
„
3 Stakeholder meetings
„
October & December 08, January 09
„
April 1 Submit rule packet to Office of
General Counsel by
„
June 25 ESRD rules will be proposed at the
DSHSC il ti DSHS
C
ounc
il
mee
ti
n
g
on
„
30 day comment period after the proposed
lblihd
ru
les are pu
bli
s
h
e
d
„
No decision yet if a public comment hearing willbeheldduringthe30daycommentperiod will
be
held
during
the
30
day
comment
period
„
DSHS responds to each comment submitted durin
g
the comment period –the comment is
either accepted and the suggested change
made oritisnotandwhy made
,
or
it
is
not
and
why
Aft t i d fi l l bl
„
Aft
er commen
t
per
io
d
,
fi
na
l ru
le pream
bl
e
and final rules go to HHSC for final approval
„
After approval, the final rules are published andbecomeeffective30daysafter and
become
effective
30
days
after
publication
wwwdshstxus/hfp/rulesshtm www
.
dshs
.
tx
.
us/hfp/rules
.
shtm
DSHS responds to each comment submitted durin
g
the comment period –the comment is
either accepted and the suggested change
made oritisnotandwhy made
,
or
it
is
not
and
why
Aft t i d fi l l bl
„
Aft
er commen
t
per
io
d
,
fi
na
l ru
le pream
bl
e
and final rules go to HHSC for final approval
„
After approval, the final rules are published andbecomeeffective30daysafter and
become
effective
30
days
after
publication
wwwdshstxus/hfp/rulesshtm www
.
dshs
.
tx
.
us/hfp/rules
.
shtm
DSHSReferralUpdate DSHSReferralUpdate DSHS
Referral
Update DSHS
Referral
Update
Referral
Update DSHS
Referral
Update
Number of Cases & Levels Number of Cases & Levels
CommonThemes CommonThemes Common
Themes Common
Themes
y
Unsafe Infection Control Practices
y
Poor hand washing practices
y
Inappropriate use of Personal Protective Equipment (PPE) (PPE)
y
Not disinfecting surfaces
y
Failure to implement Quality Assessment and
y
Failure
to
implement
Quality
Assessment
and
Performance Improvement (QAPI)
y
Patient Safety Concerns
y
Lack of patient assessments (pre, during & post)
y
Disabling machine alarms
Themes Common
Themes
y
Unsafe Infection Control Practices
y
Poor hand washing practices
y
Inappropriate use of Personal Protective Equipment (PPE) (PPE)
y
Not disinfecting surfaces
y
Failure to implement Quality Assessment and
y
Failure
to
implement
Quality
Assessment
and
Performance Improvement (QAPI)
y
Patient Safety Concerns
y
Lack of patient assessments (pre, during & post)
y
Disabling machine alarms
CommonThemes CommonThemes Common
Themes Common
Themes
y
Vascular Access Outliers
y
High Catheter Rate
y
Low AVF Rate
y
Unsafe Physical Environment
y
Dirty floors
y
Broken Tiles, etc.
y
Water Treatment Practices
y
Not testing properly
y
Lack of staff knowledge Unsafe Reuse practices
y
Unsafe
Reuse
practices
Themes Common
Themes
y
Vascular Access Outliers
y
High Catheter Rate
y
Low AVF Rate
y
Unsafe Physical Environment
y
Dirty floors
y
Broken Tiles, etc.
y
Water Treatment Practices
y
Not testing properly
y
Lack of staff knowledge Unsafe Reuse practices
y
Unsafe
Reuse
practices
Communication Issues Communication Issues
y
PCT’s not reportin
g
critical treatment
data/events to nurses:
Failuretoreport
y
Failure
to
report
y
Hyper & Hypo tension pre, during, and post dialysis
treatments
InitiatingSodiumProfilingwith
↑
BP
y
Initiating
Sodium
Profiling
with
↑
BP
y
Failure to:
y
obtain accurate weights
y
identify wet transducers
y
communicate “Reportable Parameters” to physician or nurse
y
PCT’s not reportin
g
critical treatment
data/events to nurses:
Failuretoreport
y
Failure
to
report
y
Hyper & Hypo tension pre, during, and post dialysis
treatments
InitiatingSodiumProfilingwith
↑
BP
y
Initiating
Sodium
Profiling
with
↑
BP
y
Failure to:
y
obtain accurate weights
y
identify wet transducers
y
communicate “Reportable Parameters” to physician or nurse
Serious Situations Serious Situations
y
Patient deaths attributed to nursing practice
issues
y
Phlebotomy of 1 liter of blood every treatment X 3 treatments HB ii() ih d
y
H
ep
B
pos
it
ive
(
+
)
convers
ion t
h
en converte
d
to negative (-) with pt. left in Isolation Room
forextendedperiod for
extended
period
y
Initiating dialysis when water treatment out ofparameters of
parameters
y
Patient deaths attributed to nursing practice
issues
y
Phlebotomy of 1 liter of blood every treatment X 3 treatments HB ii() ih d
y
H
ep
B
pos
it
ive
(
+
)
convers
ion t
h
en converte
d
to negative (-) with pt. left in Isolation Room
forextendedperiod for
extended
period
y
Initiating dialysis when water treatment out ofparameters of
parameters
Serious Situations Serious Situations
y
Use non-standard dialysate without
a
pp
ro
p
riate monitorin
g
pp p g
y
Failure to recognize, report and track AdverseEvents Adverse
Events
y
Use non-standard dialysate without
a
pp
ro
p
riate monitorin
g
pp p g
y
Failure to recognize, report and track AdverseEvents Adverse
Events
2008 Network #14 Growth & 2008 Network #14 Growth & Trends Trends Trends Trends • •CMS Certified Facilities CMS Certified Facilities • •Facility Ownership Facility Ownership
••
GrowthinPatientCensus GrowthinPatientCensus Growth
in
Patient
Census
Growth
in
Patient
Census
••Patients Transplanted Patients Transplanted
••
GrowthinPatientCensus GrowthinPatientCensus Growth
in
Patient
Census
Growth
in
Patient
Census
••Patients Transplanted Patients Transplanted
Network Growth Network Growth
TotalNumberofTexasDialysisFacilities TotalNumberofTexasDialysisFacilities Total
Number
of
Texas
Dialysis
Facilities Total
Number
of
Texas
Dialysis
Facilities
The ESRD Network of Texas, Inc.
CMS Annual Facility Survey Data
TotalNumberofTexasDialysisFacilities TotalNumberofTexasDialysisFacilities Total
Number
of
Texas
Dialysis
Facilities Total
Number
of
Texas
Dialysis
Facilities
The ESRD Network of Texas, Inc.
CMS Annual Facility Survey Data
Facility Ownership in Texas Facility Ownership in Texas
26
26
2008 Texas Facility Ownership (%) 2008 Texas Facility Ownership (%)
27
27
Total Number of Texas Patients Total Number of Texas Patients
(IncludesHome&In (IncludesHome&In
CenterHDandPDPatients) CenterHDandPDPatients)
(Includes
Home
&
In (Includes
Home
&
In
- -
Center
HD
and
PD
Patients) Center
HD
and
PD
Patients)
(IncludesHome&In (IncludesHome&In
CenterHDandPDPatients) CenterHDandPDPatients)
(Includes
Home
&
In (Includes
Home
&
In
- -
Center
HD
and
PD
Patients) Center
HD
and
PD
Patients)
T
otal Transplants by Donor Type
T
otal Transplants by Donor Type
29
otal Transplants by Donor Type
T
otal Transplants by Donor Type
29
2004 2004--2007 2007
St
a
n
da
r
d
ize
d
Tr
a
ns
p
la
nt
a
ti
o
n R
a
ti
o
St
a
n
da
r
d
ize
d
Tr
a
ns
p
la
nt
a
ti
o
n R
a
ti
o
adad d apaao ao adad d apaao ao
(STR) (STR)
UM KECC DFR report
St
a
n
da
r
d
ize
d
Tr
a
ns
p
la
nt
a
ti
o
n R
a
ti
o
St
a
n
da
r
d
ize
d
Tr
a
ns
p
la
nt
a
ti
o
n R
a
ti
o
adad d apaao ao adad d apaao ao
(STR) (STR)
UM KECC DFR report
2007 2007
Percent P
a
tients
(
<7
0
y
e
a
rs
o
ld)
o
n Percent P
a
tients
(
<7
0
y
e
a
rs
o
ld)
o
n
a(0yaod)o a(0yaod)o
Transplant Waitlist Transplant Waitlist
UM KECC DFR report
Percent P
a
tients
(
<7
0
y
e
a
rs
o
ld)
o
n Percent P
a
tients
(
<7
0
y
e
a
rs
o
ld)
o
n
a(0yaod)o a(0yaod)o
Transplant Waitlist Transplant Waitlist
UM KECC DFR report
2007
PercentPatientsonthe Percent
Patients
on
the
Waitlist by Subgroup
aitlist on the Wa Subgroup ercent of S Pe
PercentPatientsonthe Percent
Patients
on
the
Waitlist by Subgroup
aitlist on the Wa Subgroup ercent of S Pe
Distributionof Distributionof
PercentofTexasFacility PercentofTexasFacility
Distribution
of Distribution
of
Percent
of
Texas
Facility
Percent
of
Texas
Facility
Patients on Waitlist 2007 Patients on Waitlist 2007
UM KECC DFR report
PercentofTexasFacility PercentofTexasFacility
Distribution
of Distribution
of
Percent
of
Texas
Facility
Percent
of
Texas
Facility
Patients on Waitlist 2007 Patients on Waitlist 2007
UM KECC DFR report
Paired donation Paired donation
Matches one incompatible donor/recipient
pair to another pair with a complimentary incompatibility incompatibility
,
so that the donor of the first
p
air
g
ives to
pg
the recipient of the second, and vice versa.
Matches one incompatible donor/recipient
pair to another pair with a complimentary incompatibility incompatibility
,
so that the donor of the first
p
air
g
ives to
pg
the recipient of the second, and vice versa.
PotentialDonations PotentialDonations Potential
Donations Potential
Donations
4000
5000
anges 3000 ble Excha
•100 donor - recipient pairs generates
4,950 potential paired exchanges
2000 r of Possi
0
1000 Number
0
1 112131415161718191101
Number of Pairs
Donations Potential
Donations
4000
5000
anges 3000 ble Excha
•100 donor - recipient pairs generates
4,950 potential paired exchanges
2000 r of Possi
0
1000 Number
0
1 112131415161718191101
Number of Pairs
Alliance for Paired Donation Alliance for Paired Donation
„
Composed of 63 transplant centers in
22 states.
„
1
st
year APD facilitated 19 paired
exchanges exchanges
„
List of Texas Participating Centers (18)(18)
„
www.paireddonation.org
„
Composed of 63 transplant centers in
22 states.
„
1
st
year APD facilitated 19 paired
exchanges exchanges
„
List of Texas Participating Centers (18)(18)
„
www.paireddonation.org
PairedDonationNetwork PairedDonationNetwork Paired
Donation
Network Paired
Donation
Network
„
Includes over 80 kidney transplant programs i23tt tht idifi i l in
23
s
t
a
t
es
th
a
t
are or
g
an
ize
d
in
fi
ve re
gi
ona
l
consortia.
14p i eddono t n pl nt h ebeendone
„
14
p
a
ir
ed
dono
r
t
ra
n
s
pl
a
nt
s
h
av
e
been
done
within the PDN system since October 08.
Texas
2centers
„
Texas
–
2
centers
„
North Austin Medical Center
„
MemorialHermannRenalTransplantCenter
„
Memorial
Hermann
Renal
Transplant
Center
http://www.paireddonationnetwork.org/
Donation
Network Paired
Donation
Network
„
Includes over 80 kidney transplant programs i23tt tht idifi i l in
23
s
t
a
t
es
th
a
t
are or
g
an
ize
d
in
fi
ve re
gi
ona
l
consortia.
14p i eddono t n pl nt h ebeendone
„
14
p
a
ir
ed
dono
r
t
ra
n
s
pl
a
nt
s
h
av
e
been
done
within the PDN system since October 08.
Texas
2centers
„
Texas
–
2
centers
„
North Austin Medical Center
„
MemorialHermannRenalTransplantCenter
„
Memorial
Hermann
Renal
Transplant
Center
http://www.paireddonationnetwork.org/
Activities of the Network Activities of the Network
„
Quality Improvement
„
Outreach
„
Outreach
„
TEEC & Disaster preparedness
„
Patient&ProviderTechnicalAssistance&
„
Patient
&
Provider
Technical
Assistance
&
Education
„
InvoluntaryDischarge
„
Involuntary
Discharge
„
Information Management
„
Quality Improvement
„
Outreach
„
Outreach
„
TEEC & Disaster preparedness
„
Patient&ProviderTechnicalAssistance&
„
Patient
&
Provider
Technical
Assistance
&
Education
„
InvoluntaryDischarge
„
Involuntary
Discharge
„
Information Management
Quality Improvement Quality Improvement
„
Lab data Collection
„
QualityImprovementProjects
„
Quality
Improvement
Projects
„
Home Sweet Home
„
QualityofCareConcerns&CPM
’s
„
Quality
of
Care
Concerns
&
CPMs
„
Vascular Access Improvement Projects
„
Severe Anemia
„
Severe
Anemia
„
2 year outliers for clinical labs
„
Lab data Collection
„
QualityImprovementProjects
„
Quality
Improvement
Projects
„
Home Sweet Home
„
QualityofCareConcerns&CPM
’s
„
Quality
of
Care
Concerns
&
CPMs
„
Vascular Access Improvement Projects
„
Severe Anemia
„
Severe
Anemia
„
2 year outliers for clinical labs
PatientServicesandOutreach PatientServicesandOutreach Patient
Services
and
Outreach Patient
Services
and
Outreach
Services
and
Outreach Patient
Services
and
Outreach
Whti TEEC? Whti TEEC? Wh
a
t
is
TEEC?
Wh
a
t
is
TEEC?
Themissionof Themissionof The
mission
of
The
mission
of
TEEC is to ensure a TEEC is to ensure a
coordinated coordinated coordinated
coordinated
preparedness, plan, preparedness, plan,
res
p
onse and res
p
onse and
p p
recovery to recovery to
emergency events emergency events
ff ti th T ff ti th T
a
ff
ec
ti
n
g
th
e
T
exas a
ff
ec
ti
n
g
th
e
T
exas
ESRD community. ESRD community.
a
t
is
TEEC?
Wh
a
t
is
TEEC?
Themissionof Themissionof The
mission
of
The
mission
of
TEEC is to ensure a TEEC is to ensure a
coordinated coordinated coordinated
coordinated
preparedness, plan, preparedness, plan,
res
p
onse and res
p
onse and
p p
recovery to recovery to
emergency events emergency events
ff ti th T ff ti th T
a
ff
ec
ti
n
g
th
e
T
exas a
ff
ec
ti
n
g
th
e
T
exas
ESRD community. ESRD community.
ImportantLessonsLearned ImportantLessonsLearned Important
Lessons
Learned Important
Lessons
Learned
„
Independent facilities must pre-plan for backupdialysiswithanotherprovider backup
dialysis
with
another
provider
„
Patientsshouldbeencouragedtoevacuate
„
Patients
should
be
encouraged
to
evacuate
Anypatientwithlimitedmobility support
„
Any
patient
with
limited
mobility
,
support
systems and or transportation MUST be
registeredforevacuationwith211 registered
for
evacuation
with
211
„
Tellingpatientstogothehospitalfordialysis
„
Telling
patients
to
go
the
hospital
for
dialysis
is NOT a disaster plan!
Lessons
Learned Important
Lessons
Learned
„
Independent facilities must pre-plan for backupdialysiswithanotherprovider backup
dialysis
with
another
provider
„
Patientsshouldbeencouragedtoevacuate
„
Patients
should
be
encouraged
to
evacuate
Anypatientwithlimitedmobility support
„
Any
patient
with
limited
mobility
,
support
systems and or transportation MUST be
registeredforevacuationwith211 registered
for
evacuation
with
211
„
Tellingpatientstogothehospitalfordialysis
„
Telling
patients
to
go
the
hospital
for
dialysis
is NOT a disaster plan!
Involuntary Discharge Involuntary Discharge
44
54
46
32
40
31
< 0.15% of
total
patients
44
54
46
32
40
31
< 0.15% of
total
patients
Monitoring&ProfilingComplaints Monitoring&ProfilingComplaints Monitoring
&
Profiling
Complaints
Monitoring
&
Profiling
Complaints
by Facility by Facility
&
Profiling
Complaints
Monitoring
&
Profiling
Complaints
by Facility by Facility
PercentoftotalFacilitieswith PercentoftotalFacilitieswith Percent
of
total
Facilities
with
Percent
of
total
Facilities
with
Complaints Complaints
1 Complaint 14.7%
3 Complaints 002%
2 Complaints 1.5%
3 Complaints 0
.
02%
None 83.78%
>3 Complaints 0.0%
of
total
Facilities
with
Percent
of
total
Facilities
with
Complaints Complaints
1 Complaint 14.7%
3 Complaints 002%
2 Complaints 1.5%
3 Complaints 0
.
02%
None 83.78%
>3 Complaints 0.0%
BookletTest BookletTest Booklet
Test Booklet
Test
Fall 2008 Fall 2008 6facilities 6facilities
- -
ElPaso ElPaso
6
facilities 6
facilities
- -
El
Paso
,
El
Paso
,
Angleton, Houston, Angleton, Houston,
Tyler Lubbock Tyler Lubbock Tyler
,
Lubbock
,
Tyler
,
Lubbock
,
McAllen McAllen
55 ti t 55 ti t 55
pa
ti
en
t
s
55
pa
ti
en
t
s
In English and Spanish
http://www.esrdnetwork.org/patients/education/resources.asp
Test Booklet
Test
Fall 2008 Fall 2008 6facilities 6facilities
- -
ElPaso ElPaso
6
facilities 6
facilities
- -
El
Paso
,
El
Paso
,
Angleton, Houston, Angleton, Houston,
Tyler Lubbock Tyler Lubbock Tyler
,
Lubbock
,
Tyler
,
Lubbock
,
McAllen McAllen
55 ti t 55 ti t 55
pa
ti
en
t
s
55
pa
ti
en
t
s
In English and Spanish
http://www.esrdnetwork.org/patients/education/resources.asp
TestMethod TestMethod Test
Method Test
Method
„
9 volunteer RD’s were asked to participate
6 completed the test
–
6
completed
the
test
„
RD’s were asked to select 9 patients (if possible) with the
followin
g
characteristics to be re
p
resentative of NW 14
p
atient
gpp
population
–
43% Hispanic ethnicity n= 3
–
57% Non-Hispanic White= 4 including 1 other race, such as Asian if possible Asian
if
possible
–
30.5% Black= 2
Of the 9 patients include at least
„
Of
the
9
patients
include
at
least
„
2 Non–readers
„
1 English speaking
„
1 Spanish speaking
„
1
Spanish
speaking
Method Test
Method
„
9 volunteer RD’s were asked to participate
6 completed the test
–
6
completed
the
test
„
RD’s were asked to select 9 patients (if possible) with the
followin
g
characteristics to be re
p
resentative of NW 14
p
atient
gpp
population
–
43% Hispanic ethnicity n= 3
–
57% Non-Hispanic White= 4 including 1 other race, such as Asian if possible Asian
if
possible
–
30.5% Black= 2
Of the 9 patients include at least
„
Of
the
9
patients
include
at
least
„
2 Non–readers
„
1 English speaking
„
1 Spanish speaking
„
1
Spanish
speaking
Ask Me Three Ask Me Three
Methodology* Methodology*
„
Selected readers were given the booklet to
d
rea
d
„
Non readers had the booklet read to them in either En
g
lish or Spanish
„
After the
p
atient read the booklet
(
or had it
p(
read to them) RD’s were asked to explain
to
p
atient :
p
*
National Patient Safety Foundation National
Patient
Safety
Foundation
Methodology* Methodology*
„
Selected readers were given the booklet to
d
rea
d
„
Non readers had the booklet read to them in either En
g
lish or Spanish
„
After the
p
atient read the booklet
(
or had it
p(
read to them) RD’s were asked to explain
to
p
atient :
p
*
National Patient Safety Foundation National
Patient
Safety
Foundation
NonBlaming NonShaming Non
Blaming
,
Non
Shaming
„
“
Wearetestinghowwell
we
did
„
We
are
testing
how
well
we
did
writing this booklet so patients can
dtdhtit I ld
un
d
ers
tan
d
w
h
a
t it
says.
I
wou
ld
like to ask you a few questions to
see how well we did.
”
„
Not:
„
Not:
„
Do you understand? Dh ti?
„
D
o you
h
ave any ques
ti
ons
?
Blaming
,
Non
Shaming
„
“
Wearetestinghowwell
we
did
„
We
are
testing
how
well
we
did
writing this booklet so patients can
dtdhtit I ld
un
d
ers
tan
d
w
h
a
t it
says.
I
wou
ld
like to ask you a few questions to
see how well we did.
”
„
Not:
„
Not:
„
Do you understand? Dh ti?
„
D
o you
h
ave any ques
ti
ons
?
„
The RD then asked 3 simple questions andrecordedtheanswersawarding1 and
recorded
the
answers
awarding
1
point for each correct answer accepting
multipleanswers multiple
answers
Ath t ilddf
„
A
o
th
er ca
t
e
g
ory was
inc
lu
d
e
d
f
or
answers the RD deemed correct that
tfth
ltd
were no
t
one o
f
th
e pre-se
lec
t
e
d
answers
The RD then asked 3 simple questions andrecordedtheanswersawarding1 and
recorded
the
answers
awarding
1
point for each correct answer accepting
multipleanswers multiple
answers
Ath t ilddf
„
A
o
th
er ca
t
e
g
ory was
inc
lu
d
e
d
f
or
answers the RD deemed correct that
tfth
ltd
were no
t
one o
f
th
e pre-se
lec
t
e
d
answers
PatientScores PatientScores Patient
Scores
Patient
Scores
„„
Total score of Total score of >>
4 considered booklet 4 considered booklet
effective effective effective effective
„ „
50 of 55 50 of 55 >>
4 (91%) 4 (91%)
„ „
Ofthe5thatdidnotscoreatleast4 Ofthe5thatdidnotscoreatleast4
„ „
Of
the
5
that
did
not
score
at
least
4 Of
the
5
that
did
not
score
at
least
4
– –
1 Hispanic white spanish speaking non 1 Hispanic white spanish speaking non-- reader reader reader reader
– –
3 Non Hispanic white English reader* 3 Non Hispanic white English reader*
– –
1AfricanAmericanEnglishreader
*
1AfricanAmericanEnglishreader
*
– –
1
African
American
English
reader 1
African
American
English
reader
* *
Althou
g
h it is not known
, it is
p
ossible these
p
atients were Althou
g
h it is not known
, it is
p
ossible these
p
atients were
g,pp g,pp
marginal readers. It is common for adult poor readers or marginal readers. It is common for adult poor readers or
nonnon--readers to deny their literacy status. readers to deny their literacy status.
Scores
Patient
Scores
„„
Total score of Total score of >>
4 considered booklet 4 considered booklet
effective effective effective effective
„ „
50 of 55 50 of 55 >>
4 (91%) 4 (91%)
„ „
Ofthe5thatdidnotscoreatleast4 Ofthe5thatdidnotscoreatleast4
„ „
Of
the
5
that
did
not
score
at
least
4 Of
the
5
that
did
not
score
at
least
4
– –
1 Hispanic white spanish speaking non 1 Hispanic white spanish speaking non-- reader reader reader reader
– –
3 Non Hispanic white English reader* 3 Non Hispanic white English reader*
– –
1AfricanAmericanEnglishreader
*
1AfricanAmericanEnglishreader
*
– –
1
African
American
English
reader 1
African
American
English
reader
* *
Althou
g
h it is not known
, it is
p
ossible these
p
atients were Althou
g
h it is not known
, it is
p
ossible these
p
atients were
g,pp g,pp
marginal readers. It is common for adult poor readers or marginal readers. It is common for adult poor readers or
nonnon--readers to deny their literacy status. readers to deny their literacy status.
Average Score by Group Average Score by Group
Black A/A
Hispanic
White
Hispanic
White
ENG.
Hispanic
White
Hispanic
White
Spanish
Non
Hispanic
White
Non
Hispanic
White
Black A/A
ENG. reader
N=10
ENG. non
reader
N=1
ENG.
reader
N=10
non
reader
N=2
Spanish
reader
N=5
non
reader
N=7
ENG.
reader
N=15
Spanish
reader
N=3
5.5
9
6.3
5
5.6
4.9
4.8
8.3
5.5
9
6.3
5
5.6
4.9
4.8
8.3
Black A/A
Hispanic
White
Hispanic
White
ENG.
Hispanic
White
Hispanic
White
Spanish
Non
Hispanic
White
Non
Hispanic
White
Black A/A
ENG. reader
N=10
ENG. non
reader
N=1
ENG.
reader
N=10
non
reader
N=2
Spanish
reader
N=5
non
reader
N=7
ENG.
reader
N=15
Spanish
reader
N=3
5.5
9
6.3
5
5.6
4.9
4.8
8.3
5.5
9
6.3
5
5.6
4.9
4.8
8.3
Question #1: What is the main problem? Question #1: What is the main problem?
Ct thit Ct thit C
orrec
t
answer=
thi
rs
t C
orrec
t
answer=
thi
rs
t
Ct thit Ct thit C
orrec
t
answer=
thi
rs
t C
orrec
t
answer=
thi
rs
t
What are things I can do about it? What are things I can do about it?
(strategies to control thirst) (strategies to control thirst)
Percentresponding
Use smaller
glass , 45%
Other
approved by RD
as correct, 38%
Percent
responding
Sk
if Diabetic:
Control blood
sugar , 22%
S
uc
k
on
ice, 51%
Use
hard candy or
gum , 44%
Don't
eatprocessed eat
processed
meats , 25%
(strategies to control thirst) (strategies to control thirst)
Percentresponding
Use smaller
glass , 45%
Other
approved by RD
as correct, 38%
Percent
responding
Sk
if Diabetic:
Control blood
sugar , 22%
S
uc
k
on
ice, 51%
Use
hard candy or
gum , 44%
Don't
eatprocessed eat
processed
meats , 25%
Whyisthisimportantforme? Whyisthisimportantforme? Why
is
this
important
for
me? Why
is
this
important
for
me?
Percentresponding
less swelling, 35
not as thirsty, 29
other , 9
Percent
responding
less fluid gain,
less sob, 40
64
better for my
heart, 60
is
this
important
for
me? Why
is
this
important
for
me?
Percentresponding
less swelling, 35
not as thirsty, 29
other , 9
Percent
responding
less fluid gain,
less sob, 40
64
better for my
heart, 60
Conclusions Conclusions Conclusions Conclusions
„
The booklet effectively educated patients
fld hidi
o
f
severa
l
d
emo
g
rap
hi
cs re
g
ar
di
n
g
:
–
The main topic-with 95% answering thirst correctly correctly
–
Strategies to control thirst
„
22
-
51% cited
>
1 of 5 answers determined in
„
22
51%
cited
>
1
of
5
answers
determined
in
advance to be correct
„
38% cited another answer that the RD approved
as correct as
correct
„
Suck on ice
was the strategy scoring the highest
(51%)
„
The booklet effectively educated patients
fld hidi
o
f
severa
l
d
emo
g
rap
hi
cs re
g
ar
di
n
g
:
–
The main topic-with 95% answering thirst correctly correctly
–
Strategies to control thirst
„
22
-
51% cited
>
1 of 5 answers determined in
„
22
51%
cited
>
1
of
5
answers
determined
in
advance to be correct
„
38% cited another answer that the RD approved
as correct as
correct
„
Suck on ice
was the strategy scoring the highest
(51%)
Conclusions, continued Conclusions, continued
–
Importance to them personally
„
29
-
64%cited
>
1of5answersdetermined
29
64%
cited
>
1
of
5
answers
determined
in advance to be correct
„
Less fluid
g
ain
was the reason scorin
g
the
g
g
highest (64%)
„
Better for m
y
hear
t
second hi
g
hest
(
60%
)
y
g()
„
9% cited another answer that the RD approved as correct
–
Importance to them personally
„
29
-
64%cited
>
1of5answersdetermined
29
64%
cited
>
1
of
5
answers
determined
in advance to be correct
„
Less fluid
g
ain
was the reason scorin
g
the
g
g
highest (64%)
„
Better for m
y
hear
t
second hi
g
hest
(
60%
)
y
g()
„
9% cited another answer that the RD approved as correct
Wh
y
do all that for a booklet Wh
y
do all that for a booklet
y yeveryone likes & uses? everyone likes & uses?
„
Need to show effectiveness of outreach to
CMS
„
Learning new methods to address
„
HealthLiteracyissues
„
Health
Literacy
issues
„
Demonstrating effectiveness
y
do all that for a booklet Wh
y
do all that for a booklet
y yeveryone likes & uses? everyone likes & uses?
„
Need to show effectiveness of outreach to
CMS
„
Learning new methods to address
„
HealthLiteracyissues
„
Health
Literacy
issues
„
Demonstrating effectiveness
Health Literacy: A Prescription to End Health Literacy: A Prescription to End
Confusion. Confusion.
„
90 million US adults: literacy skills below high schoollevel school
level
„
Adults with limited literacy:
„
less knowledge of disease management & health
ibhi
promot
ing
b
e
h
av
iors
„
report poorer health status
„
less likel
y
to use
p
reventive services
yp
„
higher hospitalization rates & emergency service
use „
less adherence
„
less
adherence
„
>300 studies show health-related materials far exceed average reading ability of US adults
InstituteofMedicine 2004 Institute
of
Medicine
,
2004
Confusion. Confusion.
„
90 million US adults: literacy skills below high schoollevel school
level
„
Adults with limited literacy:
„
less knowledge of disease management & health
ibhi
promot
ing
b
e
h
av
iors
„
report poorer health status
„
less likel
y
to use
p
reventive services
yp
„
higher hospitalization rates & emergency service
use „
less adherence
„
less
adherence
„
>300 studies show health-related materials far exceed average reading ability of US adults
InstituteofMedicine 2004 Institute
of
Medicine
,
2004
Health Literacy of American Adults Health Literacy of American Adults
National Assessment of Adult
Literacy (NAAL): National
Center for Educational Statistics, U.S.
Department of Education, 2003.
National Assessment of Adult
Literacy (NAAL): National
Center for Educational Statistics, U.S.
Department of Education, 2003.
Health Literacy
„
“The degree to which individuals have the
ca
p
acit
y
to
;
py;
„
obtain,
„
process,and
„
process,
and
„
understand
„
basichealthinformationandservices
„
basic
health
information
and
services
needed to make appropriate health
decisions
”
decisions
.
Healthy People 2010
„
“The degree to which individuals have the
ca
p
acit
y
to
;
py;
„
obtain,
„
process,and
„
process,
and
„
understand
„
basichealthinformationandservices
„
basic
health
information
and
services
needed to make appropriate health
decisions
”
decisions
.
Healthy People 2010
Improves Patient Safety
„
A 2006 study examined patients’ abilities
to understand five common instructions on
prescription medications.
„
Both patients with adequate and low literacy
haddifficultyunderstandingat
literacy
had
difficulty
understanding
at
least one of the five instructions.
„
A 2006 study examined patients’ abilities
to understand five common instructions on
prescription medications.
„
Both patients with adequate and low literacy
haddifficultyunderstandingat
literacy
had
difficulty
understanding
at
least one of the five instructions.
““
What Did the Doctor Sa
y
What Did the Doctor Sa
y
?”* ?”*
Recommends making plain language a
y y
“universal precaution” in all patient
encounters
*Improving Health Literacy to Protect Patient Safety
-
Joint Commission
Safety
-
Joint
Commission
What Did the Doctor Sa
y
What Did the Doctor Sa
y
?”* ?”*
Recommends making plain language a
y y
“universal precaution” in all patient
encounters
*Improving Health Literacy to Protect Patient Safety
-
Joint Commission
Safety
-
Joint
Commission
Whatisplainlanguage? Whatisplainlanguage?
• Plain language is communication that an audience can
understand
the first time they read or hear it
What
is
plain
language? What
is
plain
language?
What
understand
the
first
time
they
read
or
hear
it
.
Wh
y
• The concept of using plain language is closely related to
the concept of health literacy.
y
•
Clear communication is critical to successful health care
How
•
Clear
communication
is
critical
to
successful
health
care
.
• Plain language is communication that an audience can
understand
the first time they read or hear it
What
is
plain
language? What
is
plain
language?
What
understand
the
first
time
they
read
or
hear
it
.
Wh
y
• The concept of using plain language is closely related to
the concept of health literacy.
y
•
Clear communication is critical to successful health care
How
•
Clear
communication
is
critical
to
successful
health
care
.
Watchformoreinformationon Watchformoreinformationon Watch
for
more
information
on
Watch
for
more
information
on
Health Literacy and Patient Education Health Literacy and Patient Education
for
more
information
on
Watch
for
more
information
on
Health Literacy and Patient Education Health Literacy and Patient Education
What happened to Crown Web? What happened to Crown Web? •Phase I-Pilot Project with 4 Networks & 8 F iliti F
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•Phase II ? Spring or Summer 09
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y
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ernoon
ac
iliti
es
•Phase II ? Spring or Summer 09
FllI l tti ??
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ti
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•For more Information-Special Session Std Aft S
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t
ur
d
a
y
Aft
ernoon
Thankyouforallthatyoudo Thankyouforallthatyoudo Thank
you
for
all
that
you
do Thank
you
for
all
that
you
do
[email protected] [email protected]
469 469
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you
for
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you
for
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do
[email protected] [email protected]
469 469
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Report from Report from
Medical Review Board Medical Review Board (MRB) (MRB)
Chairman Chairman Chairman Chairman
R b tH tki MD PhD FACP FASN R b tH tki MD PhD FACP FASN R
o
b
er
t
H
oo
tki
ns
MD
,
PhD
,
FACP
,
FASN R
o
b
er
t
H
oo
tki
ns
MD
,
PhD
,
FACP
,
FASN
Medical Review Board Medical Review Board (MRB) (MRB)
Chairman Chairman Chairman Chairman
R b tH tki MD PhD FACP FASN R b tH tki MD PhD FACP FASN R
o
b
er
t
H
oo
tki
ns
MD
,
PhD
,
FACP
,
FASN R
o
b
er
t
H
oo
tki
ns
MD
,
PhD
,
FACP
,
FASN
M
y
Assi
g
nment Toda
y
! M
y
Assi
g
nment Toda
y
!
yg y yg y
ƒ ƒ
Reviewgeographicrepresentation Reviewgeographicrepresentation Review
geographic
representation
Review
geographic
representation
and functions of MRB and functions of MRB
ƒ ƒ
Share current NW #14 clinical Share current NW #14 clinical indicator data indicator data
ƒ ƒ
Closing thoughts as outgoing Closing thoughts as outgoing
“
lameduck
”
Chairman
“
lameduck
”
Chairman
lame
duck
Chairman lame
duck
Chairman
y
Assi
g
nment Toda
y
! M
y
Assi
g
nment Toda
y
!
yg y yg y
ƒ ƒ
Reviewgeographicrepresentation Reviewgeographicrepresentation Review
geographic
representation
Review
geographic
representation
and functions of MRB and functions of MRB
ƒ ƒ
Share current NW #14 clinical Share current NW #14 clinical indicator data indicator data
ƒ ƒ
Closing thoughts as outgoing Closing thoughts as outgoing
“
lameduck
”
Chairman
“
lameduck
”
Chairman
lame
duck
Chairman lame
duck
Chairman
MRB Functions MRB Functions
ƒ ƒ
Evaluate quality and appropriateness of care Evaluate quality and appropriateness of care
delivered to ESRD patients in Texas delivered to ESRD patients in Texas ƒ ƒ
Propose Corrective Action Plans (CAP) for dialysis Propose Corrective Action Plans (CAP) for dialysis
units with Level 2 units with Level 2--3 deficiencies 3 deficiencies to Texas to Texas
DepartmentofStateHealthServices(DSHS) DepartmentofStateHealthServices(DSHS) Department
of
State
Health
Services
(DSHS)
Department
of
State
Health
Services
(DSHS)
ƒ ƒ
Analyze NW #14 data and recommend clinical Analyze NW #14 data and recommend clinical outcomeprofilingcut outcomeprofilingcut
- -
points points
outcome
profiling
cut outcome
profiling
cut
points points
ƒ ƒ
Serve as primary advisory panel to Network to Serve as primary advisory panel to Network to promote promote
improved improved
patientcareandsafety patientcareandsafety
promote
promote
improved improved
patient
care
and
safety
patient
care
and
safety
through QI activities through QI activities
ƒ ƒ
Utilize NW #14 data to identif
y
Network Utilize NW #14 data to identif
y
Network--wide wide
y y
improvement opportunities improvement opportunities
ƒ ƒ
Evaluate quality and appropriateness of care Evaluate quality and appropriateness of care
delivered to ESRD patients in Texas delivered to ESRD patients in Texas ƒ ƒ
Propose Corrective Action Plans (CAP) for dialysis Propose Corrective Action Plans (CAP) for dialysis
units with Level 2 units with Level 2--3 deficiencies 3 deficiencies to Texas to Texas
DepartmentofStateHealthServices(DSHS) DepartmentofStateHealthServices(DSHS) Department
of
State
Health
Services
(DSHS)
Department
of
State
Health
Services
(DSHS)
ƒ ƒ
Analyze NW #14 data and recommend clinical Analyze NW #14 data and recommend clinical outcomeprofilingcut outcomeprofilingcut
- -
points points
outcome
profiling
cut outcome
profiling
cut
points points
ƒ ƒ
Serve as primary advisory panel to Network to Serve as primary advisory panel to Network to promote promote
improved improved
patientcareandsafety patientcareandsafety
promote
promote
improved improved
patient
care
and
safety
patient
care
and
safety
through QI activities through QI activities
ƒ ƒ
Utilize NW #14 data to identif
y
Network Utilize NW #14 data to identif
y
Network--wide wide
y y
improvement opportunities improvement opportunities
Current Geographic Current Geographic
RepresentationofMRB RepresentationofMRB Representation
of
MRB
Representation
of
MRB
Ruben Velez, MD Ruben Velez, MD
Camille May, RN Camille May, RN
IDidMD IDidMD I
ngemar
D
av
id
son,
MD I
ngemar
D
av
id
son,
MD
Trish White, RN Trish White, RN
Mary Beth Callahan, SW Mary Beth Callahan, SW
Di
a
nn
e
M
o
r
ga
n Di
a
nn
e
M
o
r
ga
n
Jennie Lang House, RD Jennie Lang House, RD
James Cotton, MD James Cotton, MD, ,
aeoga aeoga
Mohan Narayan, MD Mohan Narayan, MD
Stuart Goldstein ,MD Stuart Goldstein ,MD
Donald Molony, MD Donald Molony, MD
Jane Louis, RD Jane Louis, RD
JliLiMD JliLiMD
Robert Hootkins, MD Robert Hootkins, MD
Deborah Heinrich, RN Deborah Heinrich, RN
Mohan
Narayan,
MD Mohan
Narayan,
MD
J
acque
li
ne
L
app
i
n,
MD J
acque
li
ne
L
app
i
n,
MD
Denise Hart, MD Denise Hart, MD
, ,
Mazeen Mazeen ArarArar, MD, MD
Jo
y
ce Hernandez
,
SW Jo
y
ce Hernandez
,
SW
Clyde Rutherford MD Clyde Rutherford MD
The ESRD Network of Texas, Inc.
y, y,
Anna Gonzalez Anna Gonzalez
Navid Navid Saigal Saigal, MD , MD
Clyde
Rutherford
,
MD Clyde
Rutherford
,
MD
Kaylenne Duran, RN
RepresentationofMRB RepresentationofMRB Representation
of
MRB
Representation
of
MRB
Ruben Velez, MD Ruben Velez, MD
Camille May, RN Camille May, RN
IDidMD IDidMD I
ngemar
D
av
id
son,
MD I
ngemar
D
av
id
son,
MD
Trish White, RN Trish White, RN
Mary Beth Callahan, SW Mary Beth Callahan, SW
Di
a
nn
e
M
o
r
ga
n Di
a
nn
e
M
o
r
ga
n
Jennie Lang House, RD Jennie Lang House, RD
James Cotton, MD James Cotton, MD, ,
aeoga aeoga
Mohan Narayan, MD Mohan Narayan, MD
Stuart Goldstein ,MD Stuart Goldstein ,MD
Donald Molony, MD Donald Molony, MD
Jane Louis, RD Jane Louis, RD
JliLiMD JliLiMD
Robert Hootkins, MD Robert Hootkins, MD
Deborah Heinrich, RN Deborah Heinrich, RN
Mohan
Narayan,
MD Mohan
Narayan,
MD
J
acque
li
ne
L
app
i
n,
MD J
acque
li
ne
L
app
i
n,
MD
Denise Hart, MD Denise Hart, MD
, ,
Mazeen Mazeen ArarArar, MD, MD
Jo
y
ce Hernandez
,
SW Jo
y
ce Hernandez
,
SW
Clyde Rutherford MD Clyde Rutherford MD
The ESRD Network of Texas, Inc.
y, y,
Anna Gonzalez Anna Gonzalez
Navid Navid Saigal Saigal, MD , MD
Clyde
Rutherford
,
MD Clyde
Rutherford
,
MD
Kaylenne Duran, RN
Informationon Informationon Information
on
Information
on
Data&Projects Data&Projects Data
&
Projects Data
&
Projects
ESRD Network of Texas, Inc. ESRD Network of Texas, Inc.
on
Information
on
Data&Projects Data&Projects Data
&
Projects Data
&
Projects
ESRD Network of Texas, Inc. ESRD Network of Texas, Inc.
Comparative Clinical Indicator Data used by NW #14
Data Collection
Mandating
Organization
Sample Size
Comparative
Data Level
Use
Clinical
Random
Network
Identify
Clinical
Performance
Measures (CPM)
CMS
Random
Sample
Patients
and U.S.
(No Facility
Specific Data)
Identify
NW QI
Projects
Quality of
Care(QOC)
Indicator Project
Network #14
100% of
eligible
patients
Facility,
Network and
U.S.
Identify
outlier
facilities
Fistula First CMS
100% of
patients
Facility,
Network and
U.S.
Identify
VA outlier
facilities
Annual Dialysis
Facility Report
CMS
All facility
patients with
URR and ESA
Medicare
Facility,
Network and
U.S.
Data
posted on
DFC and
used by
Medicare
Billing Claims SMR, SHR, STR
State
Surveyors
Data Collection
Mandating
Organization
Sample Size
Comparative
Data Level
Use
Clinical
Random
Network
Identify
Clinical
Performance
Measures (CPM)
CMS
Random
Sample
Patients
and U.S.
(No Facility
Specific Data)
Identify
NW QI
Projects
Quality of
Care(QOC)
Indicator Project
Network #14
100% of
eligible
patients
Facility,
Network and
U.S.
Identify
outlier
facilities
Fistula First CMS
100% of
patients
Facility,
Network and
U.S.
Identify
VA outlier
facilities
Annual Dialysis
Facility Report
CMS
All facility
patients with
URR and ESA
Medicare
Facility,
Network and
U.S.
Data
posted on
DFC and
used by
Medicare
Billing Claims SMR, SHR, STR
State
Surveyors
Hemodialysis Hemodialysis Hemodialysis
Hemodialysis
Adequacy Adequacy Adequacy Adequacy
Hemodialysis
Adequacy Adequacy Adequacy Adequacy
Percent of Patients Percent of Patients
with URR with URR >>
65% 65% --CPMCPM
90 90 90 90 90 90 90
89
89
89
89
89
89
9092
94
89%
90%
89
89
89
89
89
89
88 88 88
87
85
86
88
90
Patients
83
80
82
84
% of
P
76
78
14 4 6 8 12 1 16 3 9 11 13 15 US 2 7 18 10 5 17
Network
The ESRD Network of Texas, Inc.
with URR with URR >>
65% 65% --CPMCPM
90 90 90 90 90 90 90
89
89
89
89
89
89
9092
94
89%
90%
89
89
89
89
89
89
88 88 88
87
85
86
88
90
Patients
83
80
82
84
% of
P
76
78
14 4 6 8 12 1 16 3 9 11 13 15 US 2 7 18 10 5 17
Network
The ESRD Network of Texas, Inc.
Percent of Patients Percent of Patients
with Kt/V with Kt/V >>
1.2 1.2 --CPMCPM
93%
93 93 93 93 93 93
92 92 92 92 92
91
91
91
92
93
94
91%
91
91
91
90 90 90
89
8990
91
Patients
87
8687 8889
% of P
84 8586
14
4
8
9
1
16
3
6
7
12
18
13
15
US
2
10
11
5
17
14
4
8
9
1
16
3
6
7
12
18
13
15
US
2
10
11
5
17
Network
The ESRD Network of Texas, Inc.
with Kt/V with Kt/V >>
1.2 1.2 --CPMCPM
93%
93 93 93 93 93 93
92 92 92 92 92
91
91
91
92
93
94
91%
91
91
91
90 90 90
89
8990
91
Patients
87
8687 8889
% of P
84 8586
14
4
8
9
1
16
3
6
7
12
18
13
15
US
2
10
11
5
17
14
4
8
9
1
16
3
6
7
12
18
13
15
US
2
10
11
5
17
Network
The ESRD Network of Texas, Inc.
MRB Quality of Care Cut-Point for HD Adequacy (2007 data)
More than 80% of facility patients have a URR of >
65%
ƒƒ
95% of TX HD facilities (N= 391) met or 95% of TX HD facilities (N= 391) met or
d dth MRB lit t d dth MRB lit t
it! it!
excee
d
e
d
th
e
MRB
qua
lit
y cu
t
excee
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e
d
th
e
MRB
qua
lit
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t
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po
i
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ƒ ƒ
What about the 5% of TX facilities (N=19) that What about the 5% of TX facilities (N=19) that did ’ did ’
hi hi
did
n
’
t meet
did
n
’
t meet
t
h
e cut po
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h
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i
nt?
ƒ ƒ
14 facilities 14 facilities ¼ ¼71 71--80% 80% of patients had a URR of patients had a URR >>
65% 65%
ƒ ƒ
3 facilities 3 facilities
¼ ¼
61 61
- -
70% 70%
of patients had a URR of patients had a URR
> >
65% 65%
ƒ ƒ
3
facilities
3
facilities
¼ ¼
61 61
- -
70%
70%
of
patients
had
a
URR
of
patients
had
a
URR
> >
65% 65%
ƒ ƒ
1 facility 1 facility ¼ ¼51 51--60%60%of patients had a URR of patients had a URR >>
65% 65%
ƒ ƒ
1 facility 1 facility ¼ ¼0 0--10%10%of patients had a URR of patients had a URR >>
65% 65%
More than 80% of facility patients have a URR of >
65%
ƒƒ
95% of TX HD facilities (N= 391) met or 95% of TX HD facilities (N= 391) met or
d dth MRB lit t d dth MRB lit t
it! it!
excee
d
e
d
th
e
MRB
qua
lit
y cu
t
excee
d
e
d
th
e
MRB
qua
lit
y cu
t
- -po
i
n
t!
po
i
n
t!
ƒ ƒ
What about the 5% of TX facilities (N=19) that What about the 5% of TX facilities (N=19) that did ’ did ’
hi hi
did
n
’
t meet
did
n
’
t meet
t
h
e cut po
i
nt? t
h
e cut po
i
nt?
ƒ ƒ
14 facilities 14 facilities ¼ ¼71 71--80% 80% of patients had a URR of patients had a URR >>
65% 65%
ƒ ƒ
3 facilities 3 facilities
¼ ¼
61 61
- -
70% 70%
of patients had a URR of patients had a URR
> >
65% 65%
ƒ ƒ
3
facilities
3
facilities
¼ ¼
61 61
- -
70%
70%
of
patients
had
a
URR
of
patients
had
a
URR
> >
65% 65%
ƒ ƒ
1 facility 1 facility ¼ ¼51 51--60%60%of patients had a URR of patients had a URR >>
65% 65%
ƒ ƒ
1 facility 1 facility ¼ ¼0 0--10%10%of patients had a URR of patients had a URR >>
65% 65%
Hemodialysis Hemodialysis Hemodialysis
Hemodialysis
AnemiaManagement AnemiaManagement Anemia
Management Anemia
Management
Hemodialysis
AnemiaManagement AnemiaManagement Anemia
Management Anemia
Management
Percent of Patients Percent of Patients
with HGB < 10.0 with HGB < 10.0 --CPMCPM
777
8
78
9
5%
5%
444
55555555
666
5
6
7
Patients
3
2
3
4
% of
P
0
1
17 1 15 18 14 4 6 7 US 3 16 10 5 12 13 8 9 11 2
Network
The ESRD Network of Texas, Inc.
with HGB < 10.0 with HGB < 10.0 --CPMCPM
777
8
78
9
5%
5%
444
55555555
666
5
6
7
Patients
3
2
3
4
% of
P
0
1
17 1 15 18 14 4 6 7 US 3 16 10 5 12 13 8 9 11 2
Network
The ESRD Network of Texas, Inc.
Percent of Patients Percent of Patients
with HGB with HGB >>
11.0 11.0 --CPMCPM
86%
86
85
84 84
8486
88
82%
86%
83 83 83
82 82 82 82
81 81 81
80 80 80 80
80
82
84
Patients
77
76 78
% of P
72 74
14117183 71511US16125 6104 8 9132
Network
The ESRD Network of Texas, Inc.
with HGB with HGB >>
11.0 11.0 --CPMCPM
86%
86
85
84 84
8486
88
82%
86%
83 83 83
82 82 82 82
81 81 81
80 80 80 80
80
82
84
Patients
77
76 78
% of P
72 74
14117183 71511US16125 6104 8 9132
Network
The ESRD Network of Texas, Inc.
Percent of Patients Percent of Patients
with HGB 11.0 with HGB 11.0--12.0 12.0 --CPMCPM 44%
45
44
42 42 42 42
41 41
40
39 39
38
37
37
37
4045
50
39%
44%
38
37
37
37
36 36
33
32
2530
35
40
Patients
1015 2025
% of P
0 5
10
1
14
3
4
16
17
15
18
2
US
10
5
9
11
12
7
8
6
13
1
14
3
4
16
17
15
18
2
US
10
5
9
11
12
7
8
6
13
Network
The ESRD Network of Texas, Inc.
with HGB 11.0 with HGB 11.0--12.0 12.0 --CPMCPM 44%
45
44
42 42 42 42
41 41
40
39 39
38
37
37
37
4045
50
39%
44%
38
37
37
37
36 36
33
32
2530
35
40
Patients
1015 2025
% of P
0 5
10
1
14
3
4
16
17
15
18
2
US
10
5
9
11
12
7
8
6
13
1
14
3
4
16
17
15
18
2
US
10
5
9
11
12
7
8
6
13
Network
The ESRD Network of Texas, Inc.
MRBQualityofCareCut
-
Point
MRB
Quality
of
Care
Cut
Point
for HD Severe Anemia Management (2007 data)
Lessthan11%offacilitypatientshaveaHemoglobin
<
10.0
94%ofTXHDfacilities(N=413)metorexceeded 94%ofTXHDfacilities(N=413)metorexceeded
Less
than
11%
of
facility
patients
have
a
Hemoglobin
10.0
ƒƒ
94%
of
TX
HD
facilities
(N=413)
met
or
exceeded
94%
of
TX
HD
facilities
(N=413)
met
or
exceeded
the MRB quality cut the MRB quality cut--point! point!
Whataboutthe6%ofTXfacilities(N=26)that Whataboutthe6%ofTXfacilities(N=26)that
ƒ ƒ
What
about
the
6%
of
TX
facilities
(N=26)
that
What
about
the
6%
of
TX
facilities
(N=26)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
23 facilities 23 facilities ¼ ¼11 11--2020 %%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
1 facility 1 facility ¼ ¼21 21--3030%%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
1 facility 1 facility ¼ ¼41 41--50% 50% of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
0 0
1 facility 1 facility
¼ ¼
91 91
100 100
% %
of patients with Hemoglobin < of patients with Hemoglobin <
10 0 10 0
ƒ ƒ
1
facility
1
facility
¼ ¼
91 91
- -
100 100
%
%
of
patients
with
Hemoglobin
< of
patients
with
Hemoglobin
<
10
.
0 10
.
0
-
Point
MRB
Quality
of
Care
Cut
Point
for HD Severe Anemia Management (2007 data)
Lessthan11%offacilitypatientshaveaHemoglobin
<
10.0
94%ofTXHDfacilities(N=413)metorexceeded 94%ofTXHDfacilities(N=413)metorexceeded
Less
than
11%
of
facility
patients
have
a
Hemoglobin
10.0
ƒƒ
94%
of
TX
HD
facilities
(N=413)
met
or
exceeded
94%
of
TX
HD
facilities
(N=413)
met
or
exceeded
the MRB quality cut the MRB quality cut--point! point!
Whataboutthe6%ofTXfacilities(N=26)that Whataboutthe6%ofTXfacilities(N=26)that
ƒ ƒ
What
about
the
6%
of
TX
facilities
(N=26)
that
What
about
the
6%
of
TX
facilities
(N=26)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
23 facilities 23 facilities ¼ ¼11 11--2020 %%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
1 facility 1 facility ¼ ¼21 21--3030%%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
1 facility 1 facility ¼ ¼41 41--50% 50% of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
0 0
1 facility 1 facility
¼ ¼
91 91
100 100
% %
of patients with Hemoglobin < of patients with Hemoglobin <
10 0 10 0
ƒ ƒ
1
facility
1
facility
¼ ¼
91 91
- -
100 100
%
%
of
patients
with
Hemoglobin
< of
patients
with
Hemoglobin
<
10
.
0 10
.
0
MRB Quality of Care Cut-Point
for HD Anemia Mana
g
ement (2007 data)
More than 70% of facility patients have a
H l bi b
100 d 130 /dl
ƒƒ
90%ofTXHDfacilities(N
=
370)metorexceeded 90%ofTXHDfacilities(N
=
370)metorexceeded
H
emog
l
o
bi
n
b
etween >
10
.
0
an
d
<
13
.
0
gm
/dl
90%
of
TX
HD
facilities
(N
370)
met
or
exceeded
90%
of
TX
HD
facilities
(N
370)
met
or
exceeded
the MRB quality cut the MRB quality cut--point! point!
ƒ ƒ
Whataboutthe10%ofTXfacilities(N=43)that Whataboutthe10%ofTXfacilities(N=43)that
ƒ ƒ
What
about
the
10%
of
TX
facilities
(N=43)
that
What
about
the
10%
of
TX
facilities
(N=43)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
30 facilities 30 facilities ¼ ¼60.1 60.1--70%70%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
8 facilities 8 facilities ¼ ¼50. 50.11--60%60%of patients of patients >>
10.0 10.0
and and
< 13.0
g
m/dl < 13.0
g
m/dl
ƒ ƒ
4 facility 4 facility ¼ ¼40.1 40.1--50% 50% of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
1 facility 1 facility
¼ ¼
0 0
- -
10% 10%
of patients of patients
> >
10.0 10.0
and and
<
13.0 gm/dl
<
13.0 gm/dl
1
facility
1
facility
¼ ¼
0 0
10% 10%
of
patients
of
patients
10.0
10.0
and and
13.0
gm/dl
13.0
gm/dl
for HD Anemia Mana
g
ement (2007 data)
More than 70% of facility patients have a
H l bi b
100 d 130 /dl
ƒƒ
90%ofTXHDfacilities(N
=
370)metorexceeded 90%ofTXHDfacilities(N
=
370)metorexceeded
H
emog
l
o
bi
n
b
etween >
10
.
0
an
d
<
13
.
0
gm
/dl
90%
of
TX
HD
facilities
(N
370)
met
or
exceeded
90%
of
TX
HD
facilities
(N
370)
met
or
exceeded
the MRB quality cut the MRB quality cut--point! point!
ƒ ƒ
Whataboutthe10%ofTXfacilities(N=43)that Whataboutthe10%ofTXfacilities(N=43)that
ƒ ƒ
What
about
the
10%
of
TX
facilities
(N=43)
that
What
about
the
10%
of
TX
facilities
(N=43)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
30 facilities 30 facilities ¼ ¼60.1 60.1--70%70%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
8 facilities 8 facilities ¼ ¼50. 50.11--60%60%of patients of patients >>
10.0 10.0
and and
< 13.0
g
m/dl < 13.0
g
m/dl
ƒ ƒ
4 facility 4 facility ¼ ¼40.1 40.1--50% 50% of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
1 facility 1 facility
¼ ¼
0 0
- -
10% 10%
of patients of patients
> >
10.0 10.0
and and
<
13.0 gm/dl
<
13.0 gm/dl
1
facility
1
facility
¼ ¼
0 0
10% 10%
of
patients
of
patients
10.0
10.0
and and
13.0
gm/dl
13.0
gm/dl
Hemodialysis Hemodialysis Hemodialysis
Hemodialysis
BoneandMineral BoneandMineral Bone
and
Mineral
Bone
and
Mineral
Metabolism Metabolism Metabolism Metabolism
Hemodialysis
BoneandMineral BoneandMineral Bone
and
Mineral
Bone
and
Mineral
Metabolism Metabolism Metabolism Metabolism
Percent of Patients Percent of Patients
with Phosphorus 3.5 with Phosphorus 3.5--5.5 5.5 --CPMCPM
58%
49
50
51
51
51
52 52 5253 53
54 54
55 55
56
57
58
60
70
52%
58%
45
48
49
50
51
51
51
40
50
Patients
20 30
% of P
0
106
71
6
5
8
1
3
17
9
11
US
3
1
5
1
0
12 1 1
8
2414
6
6
5
8
3
9
US
3
5
0
8
Network
The ESRD Network of Texas, Inc.
with Phosphorus 3.5 with Phosphorus 3.5--5.5 5.5 --CPMCPM
58%
49
50
51
51
51
52 52 5253 53
54 54
55 55
56
57
58
60
70
52%
58%
45
48
49
50
51
51
51
40
50
Patients
20 30
% of P
0
106
71
6
5
8
1
3
17
9
11
US
3
1
5
1
0
12 1 1
8
2414
6
6
5
8
3
9
US
3
5
0
8
Network
The ESRD Network of Texas, Inc.
PeritonealDialysis PeritonealDialysis Peritoneal
Dialysis
Peritoneal
Dialysis
Adequacy Adequacy Adequacy Adequacy
Dialysis
Peritoneal
Dialysis
Adequacy Adequacy Adequacy Adequacy
Percent of PD Patients Percent of PD Patients
2006
2007
with Kt/V with Kt/V ≥ 1.7 ≥ 1.7 --QOCQOC
91.1
89.9
9095
100
2006
2007
7580
85
90
ents
6065
70
75
% of Patie
4550
55
60
%
4045
The ESRD Network of Texas, Inc.
2006
2007
with Kt/V with Kt/V ≥ 1.7 ≥ 1.7 --QOCQOC
91.1
89.9
9095
100
2006
2007
7580
85
90
ents
6065
70
75
% of Patie
4550
55
60
%
4045
The ESRD Network of Texas, Inc.
MRB Quality of Care Cut-Point
for PD Adequacy (2007 data)
More than 80% of facility patients have a Kt/V >
1.7
ƒƒ
75% of TX PD facilities (N= 84) met or exceeded 75% of TX PD facilities (N= 84) met or exceeded th MRB lit t th MRB lit t
it! it!
th
e
MRB
qua
lit
y cu
t th
e
MRB
qua
lit
y cu
t
- -po
i
n
t!
po
i
n
t!
ƒ ƒ
What about the 25% of TX facilities (N=28) that What about the 25% of TX facilities (N=28) that did ’ did ’
hi hi
did
n
’
t meet
did
n
’
t meet
t
h
e cut po
i
nt? t
h
e cut po
i
nt?
ƒ ƒ
18 facilities 18 facilities ¼ ¼71 71--80% 80% of patients met of patients met Kt/V >
1.7
ƒ ƒ
2 facilities 2 facilities
¼ ¼
61 61
- -
70% 70%
of patients met of patients met
Kt/V
>
17
ƒ ƒ
2
facilities
2
facilities
¼ ¼
61 61
- -
70%
70%
of
patients
met
of
patients
met
Kt/V
>
1
.
7
ƒ ƒ
1 facility 1 facility ¼ ¼51 51--60%60%of patients met of patients met Kt/V >
1.7
ƒ ƒ
7 facilities 7 facilities ¼ ¼0 0--50%50%of patients met of patients met Kt/V >
1.7
for PD Adequacy (2007 data)
More than 80% of facility patients have a Kt/V >
1.7
ƒƒ
75% of TX PD facilities (N= 84) met or exceeded 75% of TX PD facilities (N= 84) met or exceeded th MRB lit t th MRB lit t
it! it!
th
e
MRB
qua
lit
y cu
t th
e
MRB
qua
lit
y cu
t
- -po
i
n
t!
po
i
n
t!
ƒ ƒ
What about the 25% of TX facilities (N=28) that What about the 25% of TX facilities (N=28) that did ’ did ’
hi hi
did
n
’
t meet
did
n
’
t meet
t
h
e cut po
i
nt? t
h
e cut po
i
nt?
ƒ ƒ
18 facilities 18 facilities ¼ ¼71 71--80% 80% of patients met of patients met Kt/V >
1.7
ƒ ƒ
2 facilities 2 facilities
¼ ¼
61 61
- -
70% 70%
of patients met of patients met
Kt/V
>
17
ƒ ƒ
2
facilities
2
facilities
¼ ¼
61 61
- -
70%
70%
of
patients
met
of
patients
met
Kt/V
>
1
.
7
ƒ ƒ
1 facility 1 facility ¼ ¼51 51--60%60%of patients met of patients met Kt/V >
1.7
ƒ ƒ
7 facilities 7 facilities ¼ ¼0 0--50%50%of patients met of patients met Kt/V >
1.7
PeritonealDialysis PeritonealDialysis Peritoneal
Dialysis
Peritoneal
Dialysis
AnemiaManagement AnemiaManagement Anemia
Management Anemia
Management
Dialysis
Peritoneal
Dialysis
AnemiaManagement AnemiaManagement Anemia
Management Anemia
Management
Percent of PD Patients with Percent of PD Patients with
HGB HGB
< <
100 100
QOC QOC
HGB
HGB
< <
10
.
0
10
.
0
--
QOC QOC
The ESRD Network of Texas, Inc.
HGB HGB
< <
100 100
QOC QOC
HGB
HGB
< <
10
.
0
10
.
0
--
QOC QOC
The ESRD Network of Texas, Inc.
Percent of PD Patients Percent of PD Patients
ithHGB ithHGB
≥ ≥
110 110
QOC QOC
90
w
ith
HGB
w
ith
HGB
≥
≥
11
.
0
11
.
0
--
QOC QOC
81.9
8590
2000
2001
2002
2003
2004
2005
2006
2007
73 8
77.1
79.1
80.4
78.3
80
tients
69.2
73
.
8
70
75
% of Pat
65
%
60
The ESRD Network of Texas, Inc.
ithHGB ithHGB
≥ ≥
110 110
QOC QOC
90
w
ith
HGB
w
ith
HGB
≥
≥
11
.
0
11
.
0
--
QOC QOC
81.9
8590
2000
2001
2002
2003
2004
2005
2006
2007
73 8
77.1
79.1
80.4
78.3
80
tients
69.2
73
.
8
70
75
% of Pat
65
%
60
The ESRD Network of Texas, Inc.
Percent of PD Patients Percent of PD Patients
ithTSAT ithTSAT
≥ ≥
20% 20%
QOC QOC
w
ith
TSAT
w
ith
TSAT
≥
≥
20%
20%
--
QOC QOC
The ESRD Network of Texas, Inc.
ithTSAT ithTSAT
≥ ≥
20% 20%
QOC QOC
w
ith
TSAT
w
ith
TSAT
≥
≥
20%
20%
--
QOC QOC
The ESRD Network of Texas, Inc.
MRBQualityofCareCut
-
Point
MRB
Quality
of
Care
Cut
Point
for PD Severe Anemia Management (2007 data)
Lessthan11%offacilitypatientshaveaHemoglobin
<
10.0
77% fTXPDf iliti (N 77) t d dth 77% fTXPDf iliti (N 77) t d dth
Less
than
11%
of
facility
patients
have
a
Hemoglobin
10.0
ƒƒ
77%
o
f
TX
PD
f
ac
iliti
es
(N
=
77)
me
t
or excee
d
e
d
th
e
77%
o
f
TX
PD
f
ac
iliti
es
(N
=
77)
me
t
or excee
d
e
d
th
e
MRB quality cut MRB quality cut--point! point!
Wh t b tth 23% fTXf iliti (N 26)th t Wh t b tth 23% fTXf iliti (N 26)th t
ƒ ƒ
Wh
a
t
a
b
ou
t
th
e
23%
o
f
TX
f
ac
iliti
es
(N
=
26)
th
a
t
Wh
a
t
a
b
ou
t
th
e
23%
o
f
TX
f
ac
iliti
es
(N
=
26)
th
a
t
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
14 facilities 14 facilities ¼ ¼11 11--2020 %%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
6 facilities 6 facilities ¼ ¼21 21--3030%%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
6 facilities 6 facilities ¼ ¼41 41--50% 50% of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
-
Point
MRB
Quality
of
Care
Cut
Point
for PD Severe Anemia Management (2007 data)
Lessthan11%offacilitypatientshaveaHemoglobin
<
10.0
77% fTXPDf iliti (N 77) t d dth 77% fTXPDf iliti (N 77) t d dth
Less
than
11%
of
facility
patients
have
a
Hemoglobin
10.0
ƒƒ
77%
o
f
TX
PD
f
ac
iliti
es
(N
=
77)
me
t
or excee
d
e
d
th
e
77%
o
f
TX
PD
f
ac
iliti
es
(N
=
77)
me
t
or excee
d
e
d
th
e
MRB quality cut MRB quality cut--point! point!
Wh t b tth 23% fTXf iliti (N 26)th t Wh t b tth 23% fTXf iliti (N 26)th t
ƒ ƒ
Wh
a
t
a
b
ou
t
th
e
23%
o
f
TX
f
ac
iliti
es
(N
=
26)
th
a
t
Wh
a
t
a
b
ou
t
th
e
23%
o
f
TX
f
ac
iliti
es
(N
=
26)
th
a
t
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
14 facilities 14 facilities ¼ ¼11 11--2020 %%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
6 facilities 6 facilities ¼ ¼21 21--3030%%of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
ƒ ƒ
6 facilities 6 facilities ¼ ¼41 41--50% 50% of patients with Hemoglobin < of patients with Hemoglobin < 10.010.0
MRB Quality of Care Cut-Point
for PD Anemia Mana
g
ement (2007 data)
More than 70% of facility patients have a
H l bi b
100 d 130 /dl
66%ofTXPDfacilities(N=77)metorexceededthe 66%ofTXPDfacilities(N=77)metorexceededthe
H
emog
l
o
bi
n
b
etween >
10
.
0
an
d
<
13
.
0
gm
/dl
ƒƒ
66%
of
TX
PD
facilities
(N=77)
met
or
exceeded
the
66%
of
TX
PD
facilities
(N=77)
met
or
exceeded
the
MRB quality cut MRB quality cut--point! point!
Whataboutthe34%ofTXfacilities(N=40)that Whataboutthe34%ofTXfacilities(N=40)that
ƒ ƒ
What
about
the
34%
of
TX
facilities
(N=40)
that
What
about
the
34%
of
TX
facilities
(N=40)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
19 facilities 19 facilities ¼ ¼60.1 60.1--70%70%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
6 facilities 6 facilities ¼ ¼50. 50.11--60%60%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
9 facilities 9 facilities ¼ ¼40.1 40.1--50% 50% of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
6 facilities 6 facilities
¼ ¼
0 0
- -
40% 40%
of patients of patients
> >
10 0 10 0
and and
<130gm/dl <130gm/dl
ƒ ƒ
6
facilities
6
facilities
¼ ¼
0 0
- -
40% 40%
of
patients
of
patients
> >
10
.
0
10
.
0
and
and
<
13
.
0
gm/dl <
13
.
0
gm/dl
for PD Anemia Mana
g
ement (2007 data)
More than 70% of facility patients have a
H l bi b
100 d 130 /dl
66%ofTXPDfacilities(N=77)metorexceededthe 66%ofTXPDfacilities(N=77)metorexceededthe
H
emog
l
o
bi
n
b
etween >
10
.
0
an
d
<
13
.
0
gm
/dl
ƒƒ
66%
of
TX
PD
facilities
(N=77)
met
or
exceeded
the
66%
of
TX
PD
facilities
(N=77)
met
or
exceeded
the
MRB quality cut MRB quality cut--point! point!
Whataboutthe34%ofTXfacilities(N=40)that Whataboutthe34%ofTXfacilities(N=40)that
ƒ ƒ
What
about
the
34%
of
TX
facilities
(N=40)
that
What
about
the
34%
of
TX
facilities
(N=40)
that
didn’t meet didn’t meet
the cut point for this Hgb range? the cut point for this Hgb range?
ƒ ƒ
19 facilities 19 facilities ¼ ¼60.1 60.1--70%70%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
6 facilities 6 facilities ¼ ¼50. 50.11--60%60%of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
9 facilities 9 facilities ¼ ¼40.1 40.1--50% 50% of patients of patients >>
10.0 10.0
and and
< 13.0 gm/dl < 13.0 gm/dl
ƒ ƒ
6 facilities 6 facilities
¼ ¼
0 0
- -
40% 40%
of patients of patients
> >
10 0 10 0
and and
<130gm/dl <130gm/dl
ƒ ƒ
6
facilities
6
facilities
¼ ¼
0 0
- -
40% 40%
of
patients
of
patients
> >
10
.
0
10
.
0
and
and
<
13
.
0
gm/dl <
13
.
0
gm/dl
PeritonealDialysis PeritonealDialysis Peritoneal
Dialysis
Peritoneal
Dialysis
Albumin Albumin Albumin Albumin
Dialysis
Peritoneal
Dialysis
Albumin Albumin Albumin Albumin
Percent of PD Patients Percent of PD Patients ithALB ithALB
≥ ≥
40/37 40/37
QOC QOC
36
w
ith
ALB
w
ith
ALB
≥
≥
4
.
0/3
.
7
4
.
0/3
.
7
--
QOC QOC
27.4
24 8
283236
2000
2001
2002
2003
2004
2005
2006
2007
24
.
8
23.0
20.3
21.3
20.6
20
24
28
atients
12
16
% of P
a
4 8 0
The ESRD Network of Texas, Inc.
≥ ≥
40/37 40/37
QOC QOC
36
w
ith
ALB
w
ith
ALB
≥
≥
4
.
0/3
.
7
4
.
0/3
.
7
--
QOC QOC
27.4
24 8
283236
2000
2001
2002
2003
2004
2005
2006
2007
24
.
8
23.0
20.3
21.3
20.6
20
24
28
atients
12
16
% of P
a
4 8 0
The ESRD Network of Texas, Inc.
VascularAccess VascularAccess Vascular
Access
Vascular
Access
Management Management Management Management
Access
Vascular
Access
Management Management Management Management
AVF Utilization in the U.S. AVF Utilization in the U.S.
November 2008 November 2008
70
64
5757565555
5251 5151 51
50
50
50
49
48
48
6070
51.4%
50.5% 50
50
50
49
48
48
4747
40
50
nt AVF
20
30
Perce
0
10
16
15
17
1
2
18
3
7
US
12
14
4
11
13
10
5
8
9
6
16
15
17
1
2
18
3
7
US
12
14
4
11
13
10
5
8
9
6
Network
The ESRD Network of Texas, Inc.
November 2008 November 2008
70
64
5757565555
5251 5151 51
50
50
50
49
48
48
6070
51.4%
50.5% 50
50
50
49
48
48
4747
40
50
nt AVF
20
30
Perce
0
10
16
15
17
1
2
18
3
7
US
12
14
4
11
13
10
5
8
9
6
16
15
17
1
2
18
3
7
US
12
14
4
11
13
10
5
8
9
6
Network
The ESRD Network of Texas, Inc.
Improvement Needed to Meet CMSContractYearGoalof4% CMS
Contract
Year
Goal
of
4%
2008-2009 AVF Gap Analysis Trending - Network #14
Where we are now and where we NEED TO BE to meet
our CMS goal of 4% increase in prevalentAVFs
52.0%
52.8%
our
CMS
goal
of
4%
increase
in
prevalent
AVFs
Assuming Equal Growth each Month
Where we need to be
Where we are/were
50.3%
50.6%
50.9%
51.2%
51.5%
51.8%
52.0%
51.2%
52.0%
Rate
49.1%
49.4%
49.7%
50.0%
4
9
.
6
%
49.8%
49.9%
50.0%
50.4%
50.5%
49.6%
50.4%
AVF
R
48.5%
48.8%
49.1%
48.5%
48.6%
48.8%
9
6
%
48.0%
48.8%
M
08
A
08
M
08
J
08
Jl
08
A
08
S
08
Ot
08
N
08
D
08
J
09
Fb
09
M
09
M
a
r
-
08
A
p
r
-
08
M
a
y
-
08
J
un-
08
J
u
l
-
08
A
ug-
08
S
ep-
08
O
c
t
-
08
N
ov-
08
D
ec-
08
J
an-
09
F
e
b
-
09
M
a
r
-
09
Month
Contract
Year
Goal
of
4%
2008-2009 AVF Gap Analysis Trending - Network #14
Where we are now and where we NEED TO BE to meet
our CMS goal of 4% increase in prevalentAVFs
52.0%
52.8%
our
CMS
goal
of
4%
increase
in
prevalent
AVFs
Assuming Equal Growth each Month
Where we need to be
Where we are/were
50.3%
50.6%
50.9%
51.2%
51.5%
51.8%
52.0%
51.2%
52.0%
Rate
49.1%
49.4%
49.7%
50.0%
4
9
.
6
%
49.8%
49.9%
50.0%
50.4%
50.5%
49.6%
50.4%
AVF
R
48.5%
48.8%
49.1%
48.5%
48.6%
48.8%
9
6
%
48.0%
48.8%
M
08
A
08
M
08
J
08
Jl
08
A
08
S
08
Ot
08
N
08
D
08
J
09
Fb
09
M
09
M
a
r
-
08
A
p
r
-
08
M
a
y
-
08
J
un-
08
J
u
l
-
08
A
ug-
08
S
ep-
08
O
c
t
-
08
N
ov-
08
D
ec-
08
J
an-
09
F
e
b
-
09
M
a
r
-
09
Month
Percent of Prevalent Patients Percent of Prevalent Patients
withCatheter withCatheter
( (
with/withoutAVForAVG, with/withoutAVForAVG,
with
Catheter
with
Catheter
( (
with/without
AVF
or
AVG,
with/without
AVF
or
AVG,
regardless of duration of use regardless of duration of use ) )
- -CPMCPM
31 31 31
32 32 32
34
35
40
27%
21%
21 21
23
24 24
25
27 27 27
28 28 28
2025
30
Patients
21%
10
15
20
% of P
0 5
14
18
16
1
6
8
15
17
US
2
3
4
11
12
13
7
9
10
5
14
18
16
1
6
8
15
17
US
2
3
4
11
12
13
7
9
10
5
Network
The ESRD Network of Texas, Inc.
withCatheter withCatheter
( (
with/withoutAVForAVG, with/withoutAVForAVG,
with
Catheter
with
Catheter
( (
with/without
AVF
or
AVG,
with/without
AVF
or
AVG,
regardless of duration of use regardless of duration of use ) )
- -CPMCPM
31 31 31
32 32 32
34
35
40
27%
21%
21 21
23
24 24
25
27 27 27
28 28 28
2025
30
Patients
21%
10
15
20
% of P
0 5
14
18
16
1
6
8
15
17
US
2
3
4
11
12
13
7
9
10
5
14
18
16
1
6
8
15
17
US
2
3
4
11
12
13
7
9
10
5
Network
The ESRD Network of Texas, Inc.
Percent of Prevalent Patients Percent of Prevalent Patients
with Catheter with Catheter --CPMCPM
21
23
24
21
25
30
17
19
21
21
1520
atients
1015
% of P
0
5
2002 2003 2004 2005 2006 2007
Network 14
The ESRD Network of Texas, Inc.
with Catheter with Catheter --CPMCPM
21
23
24
21
25
30
17
19
21
21
1520
atients
1015
% of P
0
5
2002 2003 2004 2005 2006 2007
Network 14
The ESRD Network of Texas, Inc.
September 2008
Chart 2: Prevalent Texas Patients With Catheter Only
9.3
1012
ents
Oct 2003
Oct 2004
Sep 2005
Sep 2006
Sep 2007
Mar 2008
Sep 2008
5.6
8.4
52
6.2
8.9
5.6
8.3
51
8.0
5.6
8.1
52
7.9
68
10
valent Patie
5.6
5
.
2
5.6
5
.
1
5.6
5
.
2
246
cent of Prev
02
Perc
Utilizing Catheter Utilizing Catheter
>
90 Days < 90 Days
Chart 2: Prevalent Texas Patients With Catheter Only
9.3
1012
ents
Oct 2003
Oct 2004
Sep 2005
Sep 2006
Sep 2007
Mar 2008
Sep 2008
5.6
8.4
52
6.2
8.9
5.6
8.3
51
8.0
5.6
8.1
52
7.9
68
10
valent Patie
5.6
5
.
2
5.6
5
.
1
5.6
5
.
2
246
cent of Prev
02
Perc
Utilizing Catheter Utilizing Catheter
>
90 Days < 90 Days
Percent of Prevalent Patients Percent of Prevalent Patients
with AV Graft with AV Graft --CPMCPM
31%
26
30
31
30
35
22%
31%
15
1
6
1
6
17
18
19
20
21
22 22 22
23 23 23 23
26
20
25
atients
14
15
6
6
10 15
% of Pa
0 5
16
15
1
12
7
10
2
17
3
5
13
US
4
9
11
18
8
6
14
16
15
1
12
7
10
2
17
3
5
13
US
4
9
11
18
8
6
14
Network
The ESRD Network of Texas, Inc.
with AV Graft with AV Graft --CPMCPM
31%
26
30
31
30
35
22%
31%
15
1
6
1
6
17
18
19
20
21
22 22 22
23 23 23 23
26
20
25
atients
14
15
6
6
10 15
% of Pa
0 5
16
15
1
12
7
10
2
17
3
5
13
US
4
9
11
18
8
6
14
16
15
1
12
7
10
2
17
3
5
13
US
4
9
11
18
8
6
14
Network
The ESRD Network of Texas, Inc.
Percent of Prevalent Patients Percent of Prevalent Patients
with AV Graft with AV Graft --CPMCPM
56
52
44
50
60
44
32 32
31
3040
atients
2030
% of Pa
0
10
2002
2003
2004
2005
2006
2007
2002
2003
2004
2005
2006
2007
Network 14
The ESRD Network of Texas, Inc.
with AV Graft with AV Graft --CPMCPM
56
52
44
50
60
44
32 32
31
3040
atients
2030
% of Pa
0
10
2002
2003
2004
2005
2006
2007
2002
2003
2004
2005
2006
2007
Network 14
The ESRD Network of Texas, Inc.
Percent of Prevalent Patients with Percent of Prevalent Patients with
AVG d AVG d
Si Si
Mii Mii
CPM CPM
AVG
an
d
AVG
an
d
S
tenos
i
s
S
tenos
i
s
M
on
i
tor
i
ng
M
on
i
tor
i
ng --
CPM CPM
99
87
84
100
120
71%
69%
87
84
80
72 72 7271 71 71 71
69
67 67
64
62 6261
58
60
80
Patients
2040
% of P
0
20
161364381111018US141217291575
Network
The ESRD Network of Texas, Inc.
AVG d AVG d
Si Si
Mii Mii
CPM CPM
AVG
an
d
AVG
an
d
S
tenos
i
s
S
tenos
i
s
M
on
i
tor
i
ng
M
on
i
tor
i
ng --
CPM CPM
99
87
84
100
120
71%
69%
87
84
80
72 72 7271 71 71 71
69
67 67
64
62 6261
58
60
80
Patients
2040
% of P
0
20
161364381111018US141217291575
Network
The ESRD Network of Texas, Inc.
Percent of Prevalent Patients with Percent of Prevalent Patients with
AVG d AVG d
Si Si
Mii Mii
CPM CPM
AVG
an
d
AVG
an
d
S
tenos
i
s
S
tenos
i
s
M
on
i
tor
i
ng
M
on
i
tor
i
ng --
CPM CPM
90
100
78
84
80
90
atients
68
72 72
69
70
% of P a
50
60
2002 2003 2004 2005 2006 2007
Network 14
The ESRD Network of Texas, Inc.
AVG d AVG d
Si Si
Mii Mii
CPM CPM
AVG
an
d
AVG
an
d
S
tenos
i
s
S
tenos
i
s
M
on
i
tor
i
ng
M
on
i
tor
i
ng --
CPM CPM
90
100
78
84
80
90
atients
68
72 72
69
70
% of P a
50
60
2002 2003 2004 2005 2006 2007
Network 14
The ESRD Network of Texas, Inc.
Fistula First Focus Fistula First Focus
„ „
Nephrologist awareness and early referral Nephrologist awareness and early referral p
atterns
p
atterns
p p
„ „
Regional areas with system barriers Regional areas with system barriers AVGconversiontoSecondaryAVF AVGconversiontoSecondaryAVF
„ „
AVG
conversion
to
Secondary
AVF
AVG
conversion
to
Secondary
AVF
„
Focus on Assessing Failing
AVG for conversion to
Secondary AVF Secondary
AVF
„
Pilot Project Ongoing- 6 Texas Facilities with
historically high AVG rates (> 30% AVG x 3 years)
„ „
Nephrologist awareness and early referral Nephrologist awareness and early referral p
atterns
p
atterns
p p
„ „
Regional areas with system barriers Regional areas with system barriers AVGconversiontoSecondaryAVF AVGconversiontoSecondaryAVF
„ „
AVG
conversion
to
Secondary
AVF
AVG
conversion
to
Secondary
AVF
„
Focus on Assessing Failing
AVG for conversion to
Secondary AVF Secondary
AVF
„
Pilot Project Ongoing- 6 Texas Facilities with
historically high AVG rates (> 30% AVG x 3 years)
Nephrologist NephrologistProfile Report: Profile Report:
Cath + AVF
or AVG
AVF
PhysicianTexas
A
VF
AVG
Cath + AVF
or AVG
Physician Texas
Catheter Only
Catheter Only
NN
2 419
0 153
Ctht ith
Ctht ith
AVG 0.0 AVG 8.9
AVF 12.5 AVF 24.2
Physician % Texas %
12 726
16 1729 Total 100.0 Total 100.0
431 24.9
Catheter Only 75.0 Catheter Only 42.0
C
a
th
e
t
er w
ith
AVF or AVG
212.5
C
a
th
e
t
er w
ith
AVF or AVG
VA Used for First Chronic Dialysis Patients with > 12 VA Used for First Chronic Dialysis Patients with > 12
The ESRD Network of Texas, Inc.
VA
Used
for
First
Chronic
Dialysis
Patients
with
>
12
VA
Used
for
First
Chronic
Dialysis
Patients
with
>
12
Months Months Nephrologist Nephrologist PrePre--ESRD Care ESRD Care
Cath + AVF
or AVG
AVF
PhysicianTexas
A
VF
AVG
Cath + AVF
or AVG
Physician Texas
Catheter Only
Catheter Only
NN
2 419
0 153
Ctht ith
Ctht ith
AVG 0.0 AVG 8.9
AVF 12.5 AVF 24.2
Physician % Texas %
12 726
16 1729 Total 100.0 Total 100.0
431 24.9
Catheter Only 75.0 Catheter Only 42.0
C
a
th
e
t
er w
ith
AVF or AVG
212.5
C
a
th
e
t
er w
ith
AVF or AVG
VA Used for First Chronic Dialysis Patients with > 12 VA Used for First Chronic Dialysis Patients with > 12
The ESRD Network of Texas, Inc.
VA
Used
for
First
Chronic
Dialysis
Patients
with
>
12
VA
Used
for
First
Chronic
Dialysis
Patients
with
>
12
Months Months Nephrologist Nephrologist PrePre--ESRD Care ESRD Care
AVF Prevalent AVF in Texas 03 AVF Prevalent AVF in Texas 03--0808
Distributiion of Percent AVF Rate
140 100
120
acilities
60
80
Number of Fac
Sep '08 Sep '07 Sep '06
Sep
'05
20
40
N
Sep
05
Sep '04 Oct '03
10 20 30 40 50 60 70 80 90
Percent AVF Rate
0
Distributiion of Percent AVF Rate
140 100
120
acilities
60
80
Number of Fac
Sep '08 Sep '07 Sep '06
Sep
'05
20
40
N
Sep
05
Sep '04 Oct '03
10 20 30 40 50 60 70 80 90
Percent AVF Rate
0
OtherNWdata& OtherNWdata& Other
NW
data
&
Other
NW
data
&
QIProjects QIProjects QI
Projects QI
Projects
NW
data
&
Other
NW
data
&
QIProjects QIProjects QI
Projects QI
Projects
2004 2004
--
2007 2007
2004 2004
2007 2007
Standardized Mortality Ratio (SMR) Standardized Mortality Ratio (SMR)
--
2007 2007
2004 2004
2007 2007
Standardized Mortality Ratio (SMR) Standardized Mortality Ratio (SMR)
St titi ll Si ifi tSMR2004 St titi ll Si ifi tSMR2004
2007 2007
St
a
ti
s
ti
ca
ll
y
Si
gn
ifi
can
t
SMR
2004 St
a
ti
s
ti
ca
ll
y
Si
gn
ifi
can
t
SMR
2004
--
2007 2007
High High
Low Low
High
High
„ „
28 Facilities 28 Facilities
„ „
SMR range SMR range
1.22 1.22
- -
2.13 2.13
Low
Low
„ „
41 Facilities 41 Facilities
„ „
SMR range SMR range
0.00 0.00
- -
0.74 0.74
„ „
SMR
range
SMR
range
1.22 1.22
2.13 2.13
„ „
P value range 0.000 P value range 0.000--0.26 0.26
„ „
Patient Census 38 Patient Census 38--312312
„ „
SMR
range
SMR
range
0.00 0.00
0.74
0.74
„ „
P value range 0.00 P value range 0.00--0.049 0.049
„ „
Patient Census 29 Patient Census 29--372372
„ „
MRB follow up in progress MRB follow up in progress
2007 2007
St
a
ti
s
ti
ca
ll
y
Si
gn
ifi
can
t
SMR
2004 St
a
ti
s
ti
ca
ll
y
Si
gn
ifi
can
t
SMR
2004
--
2007 2007
High High
Low Low
High
High
„ „
28 Facilities 28 Facilities
„ „
SMR range SMR range
1.22 1.22
- -
2.13 2.13
Low
Low
„ „
41 Facilities 41 Facilities
„ „
SMR range SMR range
0.00 0.00
- -
0.74 0.74
„ „
SMR
range
SMR
range
1.22 1.22
2.13 2.13
„ „
P value range 0.000 P value range 0.000--0.26 0.26
„ „
Patient Census 38 Patient Census 38--312312
„ „
SMR
range
SMR
range
0.00 0.00
0.74
0.74
„ „
P value range 0.00 P value range 0.00--0.049 0.049
„ „
Patient Census 29 Patient Census 29--372372
„ „
MRB follow up in progress MRB follow up in progress
2004 2004--2008 2008
Patients Patients on on Incenter Incenter& Home & Home Dialysis Dialysis
ents er of Patie Numbe
Patients Patients on on Incenter Incenter& Home & Home Dialysis Dialysis
ents er of Patie Numbe
IncreasingHomeDialysis IncreasingHomeDialysis Increasing
Home
Dialysis
Increasing
Home
Dialysis
Quality Improvement Project Quality Improvement Project
Benchmark facility results Benchmark facility results
Important practices in Important practices in educating, referring educating, referring, & , &
recruitingpatientsforhome recruitingpatientsforhome
dialysis dialysis
recruiting
patients
for
home
recruiting
patients
for
home
dialysis dialysis
Staff member(s) assigned to role of home dialysis patient education specialist or coordinator. Facility has a strong physician advocate for home dialysis. Facility has a separate Home Dialysis Program with separate staff from the in-center program. Facility has processes that empower nurses & SWs to educate patients & encourage home
dialysis.
Facility has formal home dialysis patient education protocol initiated on all new patients .
recruitingpatientsforhome recruitingpatientsforhome
dialysis dialysis
recruiting
patients
for
home
recruiting
patients
for
home
dialysis dialysis
Staff member(s) assigned to role of home dialysis patient education specialist or coordinator. Facility has a strong physician advocate for home dialysis. Facility has a separate Home Dialysis Program with separate staff from the in-center program. Facility has processes that empower nurses & SWs to educate patients & encourage home
dialysis.
Facility has formal home dialysis patient education protocol initiated on all new patients .
Important practices in Important practices in educating, referring educating, referring, & , &
recruiting recruiting
patientsforhome patientsforhome
dialysis dialysis
recruiting
recruiting
patients
for
home
patients
for
home
dialysis dialysis
New staff receive education on home dial ysis during orientation & regularly. Reassess new patients' suitability for home dialysis 3 and 6 months after dialysis is initiated &
then annually.
Home Dialysis “awareness days” done for in-center HD New patients re-educated on home dialysis options 3 and 6 months after dialysis is initiated.
Referral assessment tool with specific criteria utili zed to determine suitability for home dialysis.
recruiting recruiting
patientsforhome patientsforhome
dialysis dialysis
recruiting
recruiting
patients
for
home
patients
for
home
dialysis dialysis
New staff receive education on home dial ysis during orientation & regularly. Reassess new patients' suitability for home dialysis 3 and 6 months after dialysis is initiated &
then annually.
Home Dialysis “awareness days” done for in-center HD New patients re-educated on home dialysis options 3 and 6 months after dialysis is initiated.
Referral assessment tool with specific criteria utili zed to determine suitability for home dialysis.
Change in facilities with Home Change in facilities with Home
Pti t Pti t P
a
ti
en
t
s
P
a
ti
en
t
s
Baseline2006 Baseline2006
AfterProject2008 AfterProject2008
Baseline
2006 Baseline
2006
After
Project
2008 After
Project
2008
Pti t Pti t P
a
ti
en
t
s
P
a
ti
en
t
s
Baseline2006 Baseline2006
AfterProject2008 AfterProject2008
Baseline
2006 Baseline
2006
After
Project
2008 After
Project
2008
Improving Improving Improving
Improving
Managementof Managementof Management
of
Management
of
Phosphorus Phosphorus Phosphorus
Phosphorus
Outcomes Outcomes Outcomes
Outcomes
Improving
Managementof Managementof Management
of
Management
of
Phosphorus Phosphorus Phosphorus
Phosphorus
Outcomes Outcomes Outcomes
Outcomes
Rationale and Goals Rationale and Goals
„ „
Phosphorus is important Phosphorus is important
„ „
Mortality Mortality Mortality Mortality
„ „
Quality of Life Quality of Life
„ „
Thereisvariabilityacrossfacilities Thereisvariabilityacrossfacilities
„ „
There
is
variability
across
facilities There
is
variability
across
facilities
„ „
Project Goals Project Goals
Increasepercentofpatientsintargetrange Increasepercentofpatientsintargetrange
„ „
Increase
percent
of
patients
in
target
range Increase
percent
of
patients
in
target
range
„ „
Phosphorus is important Phosphorus is important
„ „
Mortality Mortality Mortality Mortality
„ „
Quality of Life Quality of Life
„ „
Thereisvariabilityacrossfacilities Thereisvariabilityacrossfacilities
„ „
There
is
variability
across
facilities There
is
variability
across
facilities
„ „
Project Goals Project Goals
Increasepercentofpatientsintargetrange Increasepercentofpatientsintargetrange
„ „
Increase
percent
of
patients
in
target
range Increase
percent
of
patients
in
target
range
Distribution of Facilities By Percent of PD Distribution of Facilities By Percent of PD
Patientswith Patientswith
SerumPhosphorus55mg/dl SerumPhosphorus55mg/dl
orLower orLower
Patients
with
Patients
with
Serum
Phosphorus
5
.
5
mg/dl
Serum
Phosphorus
5
.
5
mg/dl
or
Lower or
Lower
QOC Concern
Opportunity
toImprove
Benchmarks
to
Improve
2007 Quality of Care Project (4
th
Quarter 2006 data)
Mean = 62.8
St Dev = 25.71
Patientswith Patientswith
SerumPhosphorus55mg/dl SerumPhosphorus55mg/dl
orLower orLower
Patients
with
Patients
with
Serum
Phosphorus
5
.
5
mg/dl
Serum
Phosphorus
5
.
5
mg/dl
or
Lower or
Lower
QOC Concern
Opportunity
toImprove
Benchmarks
to
Improve
2007 Quality of Care Project (4
th
Quarter 2006 data)
Mean = 62.8
St Dev = 25.71
Observational Data Have Shown Elevated Serum Observational Data Have Shown Elevated Serum
Phosphorus Levels Are Associated With Increased Mortality Phosphorus Levels Are Associated With Increased Mortality
Study Data Population N PO4
(mg/dL)
Increased
Relative Risk
Sli i Y t l Sli i Y t l
19931993
19961996
DMMSDMMS
14 829 14 829
5454
6363
2%2%
Sli
n
in
Y
, e
t
a
l.
Sli
n
in
Y
, e
t
a
l.
19931993
--
1996 1996
DMMS DMMS
14
,
829 14
,
829
5
.
45
.
4
- -
6
.
36
.
3
6.4 6.4--7.57.5
> 7.5 > 7.5
2% 2%
10% 10%
19%19%
Melamed EW et Melamed EW et
1995 1995
- -
1998 1998
CHOICE CHOICE
593 593
51 51
- -
60* 60*
8% 8%
Melamed
EW
,
et
Melamed
EW
,
et
al.al.
1995 1995
- -
1998 1998
CHOICE CHOICE
593 593
5
.
15
.
1
- -
6
.
0*6
.
0*
> 6.0* > 6.0*
8% 8%
57% 57%
Block GA, et al. Block GA, et al. 19971997 FMC FMC
Database Database
40,538 40,538 5.05.0--5.55.5
5.5 5.5
- -
6.0 6.0
10% 10% 25% 25%
5.5 5.5
6.0 6.0
25% 25%
Young EW, et al. Young EW, et al. 19961996--2001 2001 DOPPSDOPPS 17,23617,236 Per 1 Per 1
mg/dL mg/dL
4%4%
Kalantar Kalantar--Zadeh, Zadeh, 20012001--2003 2003 DaVita DaVita 58,05858,058 >>
6.0* 6.0* Increased Increased††
et al. et al. DatabaseDatabase
*Adjusted for vitamin D administration.
†Exact number not specified.
Phosphorus Levels Are Associated With Increased Mortality Phosphorus Levels Are Associated With Increased Mortality
Study Data Population N PO4
(mg/dL)
Increased
Relative Risk
Sli i Y t l Sli i Y t l
19931993
19961996
DMMSDMMS
14 829 14 829
5454
6363
2%2%
Sli
n
in
Y
, e
t
a
l.
Sli
n
in
Y
, e
t
a
l.
19931993
--
1996 1996
DMMS DMMS
14
,
829 14
,
829
5
.
45
.
4
- -
6
.
36
.
3
6.4 6.4--7.57.5
> 7.5 > 7.5
2% 2%
10% 10%
19%19%
Melamed EW et Melamed EW et
1995 1995
- -
1998 1998
CHOICE CHOICE
593 593
51 51
- -
60* 60*
8% 8%
Melamed
EW
,
et
Melamed
EW
,
et
al.al.
1995 1995
- -
1998 1998
CHOICE CHOICE
593 593
5
.
15
.
1
- -
6
.
0*6
.
0*
> 6.0* > 6.0*
8% 8%
57% 57%
Block GA, et al. Block GA, et al. 19971997 FMC FMC
Database Database
40,538 40,538 5.05.0--5.55.5
5.5 5.5
- -
6.0 6.0
10% 10% 25% 25%
5.5 5.5
6.0 6.0
25% 25%
Young EW, et al. Young EW, et al. 19961996--2001 2001 DOPPSDOPPS 17,23617,236 Per 1 Per 1
mg/dL mg/dL
4%4%
Kalantar Kalantar--Zadeh, Zadeh, 20012001--2003 2003 DaVita DaVita 58,05858,058 >>
6.0* 6.0* Increased Increased††
et al. et al. DatabaseDatabase
*Adjusted for vitamin D administration.
†Exact number not specified.
Continuin
g
O
pp
ortunities for Continuin
g
O
pp
ortunities for
gpp gpp
Improvement in Texas Improvement in Texas
„ „
Barriers: Funding&NWResources Barriers: Funding&NWResources
„ „
Barriers:
Funding
&
NW
Resources Barriers:
Funding
&
NW
Resources
Pt tilPj t Pt tilPj t
„ „
P
o
t
en
ti
a
l
P
ro
j
ec
t
s:
P
o
t
en
ti
a
l
P
ro
j
ec
t
s:
K+ Baths / Protocols K+ Baths / Protocols
Abx/Cult Practices Abx/Cult Practices ––Protocols? Protocols? CatheterManagement CatheterManagement Catheter
Management Catheter
Management
g
O
pp
ortunities for Continuin
g
O
pp
ortunities for
gpp gpp
Improvement in Texas Improvement in Texas
„ „
Barriers: Funding&NWResources Barriers: Funding&NWResources
„ „
Barriers:
Funding
&
NW
Resources Barriers:
Funding
&
NW
Resources
Pt tilPj t Pt tilPj t
„ „
P
o
t
en
ti
a
l
P
ro
j
ec
t
s:
P
o
t
en
ti
a
l
P
ro
j
ec
t
s:
K+ Baths / Protocols K+ Baths / Protocols
Abx/Cult Practices Abx/Cult Practices ––Protocols? Protocols? CatheterManagement CatheterManagement Catheter
Management Catheter
Management
Closing thoughts Closing thoughts
„ „
Safety / Risks Safety / Risks
StaffOversight/Vigilance StaffOversight/Vigilance Staff
Oversight
/
Vigilance Staff
Oversight
/
Vigilance
DSHS Collaboration DSHS Collaboration Mdi lDi t C it t Mdi lDi t C it t M
e
di
ca
l
Di
rec
t
or
C
omm
it
men
t M
e
di
ca
l
Di
rec
t
or
C
omm
it
men
t
“We Can Do Better” “We Can Do Better”
„ „
Safety / Risks Safety / Risks
StaffOversight/Vigilance StaffOversight/Vigilance Staff
Oversight
/
Vigilance Staff
Oversight
/
Vigilance
DSHS Collaboration DSHS Collaboration Mdi lDi t C it t Mdi lDi t C it t M
e
di
ca
l
Di
rec
t
or
C
omm
it
men
t M
e
di
ca
l
Di
rec
t
or
C
omm
it
men
t
“We Can Do Better” “We Can Do Better”
“The medical direction of dialysis facilities hasbeen sometimesabsent feckless
*
or
has
been
…
sometimes
absent
,
feckless
or
uninspired”
*lacking purpose
without skill
ineffective
,
incom
p
etent
G t 2007
,p
lacking the courage to act in any meaningful way
G
u
t
man,
2007
*
or
has
been
…
sometimes
absent
,
feckless
or
uninspired”
*lacking purpose
without skill
ineffective
,
incom
p
etent
G t 2007
,p
lacking the courage to act in any meaningful way
G
u
t
man,
2007
CMS 2744 (2004-2006)
Annual Facility Survey Data
Fistula Fistula
First First
SdSd
Re
g
ional Re
g
ional
Fistula Fistula
First
First
Dashboard Data Dashboard Data
S
econ
d
ary
S
econ
d
ary
AVF VAIP AVF VAIP
g g
Collaborative Collaborative
VA Workshops VA Workshops
&
Quality of Care Quality of Care
“Concern” Facilities “Concern” Facilities
Quality of Care Quality of Care
Indicator Data Indicator Data
CMS 2728 (2007) CMS 2728 (2007)
MedicalEvidenceReport Form MedicalEvidenceReport Form
Access in Use at Access in Use at
Initiation of Dial
y
sis Initiation of Dial
y
sis
Clinical Performance
Improving
Phosphorous
Medical
Evidence
Report
Form Medical
Evidence
Report
Form
y y
Measures (CPM) Data
Phosphorous
Management
Reco
g
nitions
g
g
nitions
g
Tags
Categories
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