Vaccinations: Increase Hepatitis B and

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1 Vaccinations: Increase Hepatitis B and C.4.1.D.4 - Pneumococcal Pneumonia Vaccination Rates ESRD Network # Network 9 ESRD Network IPRO ESRD Network of the Ohio River Valley Name Contract Number Contract # HHSM C Title of the QIA Improve Vaccination Rates Aim, Domain and C.4.1.D.4: Vaccinations Increase Rates Sub Domain QIA Contact Person Deborah DeWalt, MSN, RN Quality Improvement Director Susan Swan-Blohm, BS, OCDT-Quality Improvement Coordinator Contracting Officer s Representative Current Date Submission Date/Version I. Objectives Commander Todd Johnson, MSW, LCSW, BCD, CDR Division of Quality Improvement Centers for Medicare & Medicaid Services December 20, 2016 December 31, 2016/Version 1 Topic Hepatitis B and pneumonia can lead to serious complications and death in the dialysis population. The Network will work with facilities that have a low rate of hepatitis B (HBV) and pneumococcal vaccinations to increase the rate of both vaccinations and to improve the accuracy of data reporting in CROWNWeb. The Network will assist facilities in achieving better health for the ESRD population through vaccination of patients to prevent them from contracting pneumonia or hepatitis B. Selected facilities will be included in the Network target group until they achieve a vaccination rate of greater than or equal to 60% for each of the two vaccines. The Network will increase the number of patients who receive both vaccinations by 3% from baseline during option year 1 of the contract (2017), with incremental escalation of this goal across the remaining option years. Root Cause Analysis (RCA) Overview and Interventions Based on the background information and in keeping with the goal of increasing vaccination rates for pneumococcal pneumonia and hepatitis B, the vaccination project will identify the root causes of low vaccination rates and to assist facilities in adopting best practices to improve the vaccination process. Facility staff will conduct an RCA during January 2017 to identify the most likely causes of low vaccination rates. These RCAs will be used to tailor interventions to the facilities' individual intervention needs. Project interventions will include, but are not limited to: Establishment and engagement with a lead contact in each facility to maintain communications throughout the project. Establishment of a patient Subject Matter Expert (SME)/ambassador within the facilities to assist with vaccination education and support vaccination project efforts. Creation of an RCA tool for facilities to use to develop targeted interventions. Utilization of the Plan-Do-Study-Act (PDSA) cycle, working with facility staff to: o Assess each facility's current immunization rate, o Identify barriers and set benchmarks for performance in each facility, o Determine the effectiveness of facility specific interventions and 1

2 III. Background modify facility benchmarks or interventions as needed. Use of facility specific data analysis and feedback to encourage goal obtainment and support information exchange and sharing of best practices. Implementation of rapid cycle improvement in testing interventions. Provision of ongoing surveillance of facility data throughout Option Year 1 (OY1). Incorporation of Healthcare Associated Infection Learning and Action Network (HAI LAN) and SME ideas and feedback in all phases of project development. Outline The Network s primary goal for OY1 is to improve the vaccination rate by 3% for both the pneumococcal and hepatitis B vaccines for all facilities participating in the QIA. Using CROWNWeb clinical data fields, the National Coordinating Center (NCC) will supply the data needed to guide the selection of facilities and to establish the baseline rate. Facilities who have achieved the QIA goals in 2016 will graduate out and require replacement. The Network will use the NCC data from 2016 to identify facilities to replace graduating facilities in order to maintain the QIA participation requirement of at least ten percent of the Network s lowest performing facilities. The intervention period will span January 2017 through September 2017.The Network will evaluate facilities participating in the QIA in November of 2017 and follow the same process to graduate facilities out who have achieved the vaccination rates of greater than or equal to 60% for both vaccines as well as replace with facilities in the lowest performing ten percent of the Network. Approximately 18,000 patients die each year from pneumococcal disease. Treatment with antibiotics is becoming increasingly less effective due to the bacteria becoming drug resistant over time 1. Hepatitis B is also a serious disease, which affects the liver, with 2,000 to 4,000 hepatitis B patients dying from cirrhosis or liver cancer each year 2. Dialysis patients are at greater risk than the general population for complications related to both pneumococcal pneumonia and hepatitis B. Vaccination is generally considered to be the most effective and least costly disease prevention therapy. The first pneumococcal polysaccharide vaccine was licensed in 1977 and the hepatitis B vaccine was first available in Despite how long these vaccinations have been available in the US, and the high risk of serious disease or death to this vulnerable population, a low percentage of patients are receiving them. While no recent data has been made available, in 2008 the national pneumococcal vaccination rate for dialysis patients was 25.2% and the hepatitis B vaccine rate for dialysis patients was 28% 4. Based on NCC data from September 2016, Network 9 rates for the pneumococcal and hepatitis B vaccines were 40.88% and 36.46% respectively, still significantly under CMS' target rate. Barriers to vaccination vary by patient, provider, and institutional system. Patients may not receive vaccinations because they are not aware of recommended 1 CDC. Vaccine Information Statement PVC Vaccine, 11/05/2015, 2 CDC, Vaccine Information Statement Hepatitis B Vaccine, 2/2/2012, 3 CDC, The Pink Book: Course Textbook 13 th Edition (2015), 4 U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD,

3 practices, have misconceptions about vaccines, or have not been encouraged by health care providers. 5 A survey conducted by AARP in 2009 additionally identified financial reasons and a lack of understanding of the importance of vaccinations as barriers for patients. 6 To improve pneumococcal pneumonia and hepatitis B vaccine rates, the Network will develop strategies for system changes by identifying common root causes of under-vaccination within individual facilities and by applying evidence based interventions tailored to overcome barriers. The Network will instruct and facilitate the use of a PDSA cycle to monitor quality improvement. Facilities will be asked to utilize rapid cycle improvement methods to test and implement strategies used. A key focus of this work will be aimed at identifying and overcoming patient barriers through education and communication. IV. Methodology Facility Selection The Network will utilize data reports provided by the NCC to guide facility selection. These reports, which are compiled using data fields from CROWNWeb, will help the Network to identify facilities with the lowest rates of vaccination for: Pneumococcal Pneumonia Hepatitis B After reviewing this data, the Network will select facilities performing in the lowest 10% of the Network, up to a maximum of 25 facilities for this activity. Inclusion Criteria Facilities in the lowest tenth percentile for both vaccines 10% of underperforming facilities to a maximum of 25 facilities Exclusion Criteria Facilities that opened during CY 2016, due to a lack of complete data Veteran Administration facilities Pediatric facilities Facility Notification Facilities will be notified by of their inclusion in the project and will be asked to complete a project agreement form that requires: acknowledgement of their participation via signatures of the medical director and administrator/nurse manager, Identification of a project lead and a facility patient representative, and Primary contact information. The project lead and facility patient representative will be the points of contact between the Network and facility for all communications. This designation will help to ensure that requested interventions are completed, the patient perspective is considered at each facility, and related information is submitted to the Network. The facility lead will also be responsible for ensuring that data is entered into CROWNWeb as appropriate. Interventions Facility Level Root Cause Analysis (RCA) The Network will develop an easy to use RCA to identify barriers at both the facility and patient levels. This will be distributed to all providers in the project with an anticipated return to the Network in February. Interventions will be developed to meet the most commonly identified findings from these analyses. 5 Patel, Priti, Overcoming Barriers and Other How To s 6 AARP 2009: Keenan T. Preventive Health Screenings among Midlife and Older Adults, interviews conducted for AARP by Woelfel Research, Inc. from December 2 to December 11, AARP Knowledge Management, February

4 Perceived Barriers and Resolutions Patient refusal/lack of understanding development of educational materials for patients who have refused vaccinations. Healthcare provider mistrust have patient representatives work individually with patients who are experiencing mistrust to assist with removing barriers. Need for system development of reminders development of standing orders and/or automatic reminders for vaccinations in collaboration with facilities. Inadequate documentation Educate providers on the correct method to document vaccinations received in their facility and at another facility. Lack of resources to track vaccinations- Implement adult immunization record process to assist patients and providers in tracking former vaccination history. Lack of patient education Identify and provide resources for staff and patient education from the CDC and other national sources. Insurance/financial barriers Work with the community to identify barriers and share best practices and billing resources. Evaluation The Network will provide a monthly evaluation of each facility s progress to goal utilizing the current CROWNWeb data and information obtained from PDSA cycle reviews starting in January 2017 and running through the end of September Facilities will be notified of their progress toward goal through monthly correspondence and Network communication releases. As part of rapid cycle improvement, individual conference calls will be held with facilities not showing improvement to identify barriers, brain storm potential solutions/interventions, and update their RCA corrective action plan. Sustainability To assist in understanding how to best prepare practitioners for sustaining improvements, an analysis of common barriers and current processes must be undertaken. After a review of that analysis, the Network will incorporate into the project, strategies aimed at sustaining work that removes common barriers and improves current processes based on the model identified by the National Institutes of Health (NIH). These strategies include: Engaging leadership Medical directors, facility administrators and nurse managers will be included in all facility communications and invited to participate in all levels of interaction regarding the project. Developing an influential team The Network will leverage key members of the Medical Review Board, HAI LAN, and patient SMEs in developing the project plan, education, communication, and resources. Sharing benefits of the program The marketing of this program to the targeted facilities will include education of staff and patients throughout the project and during site visits. Emphasis will be placed on highlighting the benefits of the program at the facility level. Provide evidence to support the project The Network will identify and send resources from the CDC and other national sources to support this project. Share progress of the project through monitoring The Network will analyze each facility s data upon receipt of each NCC database, and will send out facility specific monthly reports to each provider. Staff Involvement and Training Staff training will include webinars, distribution of educational materials, and conference calls as needed. The facilities will be encouraged to have all disciplines (social workers, dietitians, nurses, and technicians) trained in discussing and 4

5 educating patients about the importance of vaccination to increase the spread of information and improve sustainability. Patient Involvement and Training Research and best practices have demonstrated that units with active participation of patients as members of the health care team achieve better clinical outcomes more readily. This year, the Network is requesting that each facility designate at least one patient, or preferably, one patient per shift, to take the lead on special projects. We will provide training for these patients to supervise these programs in the clinic. Patients should be viewed as role models in the unit as far as the ability to lead and become the unofficial spokesman on the care team. In this role, the patient will: Provide contact information to the Network, Participate in educational and informational web conference presentations with the Network, and Review educational materials designed for patients in the target facilities and throughout the Network community. Intervention Tools and Strategies Staff education site visits, brochures, and materials Provid ers Patients Patient education materials, brochures from known sources Technical assistance Advisory Committee Root Cause Analysis Identify barriers Facility Level Patient Ambassador The Network has received CROWNWeb data from the NCC to enable facility selection and progress monitoring on a monthly basis. A list of selected facilities will be submitted to the NCC. The NCC will then provide performance data for the selected facilities to the Network on a monthly basis. Baseline Rate Calculation Pneumococcal Pneumonia Vaccine The pneumococcal pneumonia vaccine is given every five (5) years. Some patients being serviced within a particular facility may have already received the vaccine in the past five (5) years at a provider other than the dialysis facility. These patients will count as eligible until other documentation is identified and this information is entered into CROWNWeb as appropriate. Numerator - The number of patients who received the pneumococcal vaccine during the baseline period (January 1 December 31, 2016) Denominator- The number of patients in the facility who were eligible to receive the vaccination during the baseline (January 1 December 31, 2016) Hepatitis B Vaccine Patients will be counted in the numerator if they have either received the complete vaccination series (3 vaccinations) or have evidence of having seropositive antigens. Patients excluded from the denominator will be those that have immunity for hepatitis B, have had the complete vaccination series, or have declined the vaccine for medical reasons. The patient would need to have levels for hepatitis B surface antibodies (>10 miu/ml) in CROWNWeb to be removed from the denominator. 5

6 Numerator - The number of patients who completed the hepatitis vaccinations series or have a seropositive antigen level >10 miu/ml during baseline period (January December 2016) Denominator - The number of eligible patients in the facility during baseline period (January December 2016) minus those patients who are excluded as noted above. Re-measure Rate Calculation Data will be evaluated monthly with a final re- measure using September 2017 data (available in December 2017). To determine the rate of improvement from the baseline, the data from each month will be aggregated until the final remeasure. Pneumococcal Vaccine Numerator - The cumulative number of patients that received the pneumococcal vaccine during the re-measure period, ending in September 2017 Denominator - The number of eligible patients in the facility during the remeasure period, ending in September 2017 Cumulative - Add prior month of vaccinations to current month throughout remeasure period. Hepatitis B Vaccine Numerator - The cumulative number of patients that completed the hepatitis vaccinations series during the re-measure period, ending in September 2017 Denominator - The number of eligible patients in the facility during the remeasure period, ending in September 2017 Network Monthly Progress to Goal of 3% Improvement* Total # of Eligible Patient census Number of Patients receiving vaccination* Cumulative Patients receiving vaccination* Baseline February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 *A separate table will be used for each vaccination measure (pneumococcal/hepatitis B). %/ratio of vaccinations* 6

7 V. Expected Results VI. Appendices Project Timeline - February 2016 to September 2016 January 2017 Notify facilities of inclusion in the project including the timeline of interventions and project agreement forms. Distribute RCA templates to identified facilities. Collect and review facility RCAs. Convene kickoff webinar for selected facilities. February - March 2017 Establish baseline for selected facilities. Meet with patient SMEs and facility patient representatives to discuss plan and materials for resource development and education. Review each target facility's RCA. Make phone contact with each facility's lead personnel to train on and establish a PDSA cycle. Start monthly distribution of facility progress reports. Develop and distribute resources. April - May 2017 Initiate calls with underperforming facilities based on analysis of facility progress reports. Offer best practice call to create a Learning and Action Network within targeted facilities. Assure NIH sustainability strategies are being deployed effectively. June - September 2017 Distribute monthly facility progress reports. Conduct monthly evaluation of facility and Network progress toward goals. Evaluate and adjust interventions as needed. Collect best practices and benchmarks, and present webinar to targeted facilities. Continue conference calls with facilities not progressing toward goal to discuss barriers, identify potential solutions, and offer alternate interventions. September 2017 Project completed for base year. Final re-measure. Assure sustainability strategies in place in all target facilities. The goals of the HAI Vaccination QIA include: Network Improve vaccination rates for both pneumococcal pneumonia and hepatitis B by 3% from baseline (January 1 December 31, 2016) by the end of the third quarter of 2017 (September 30, 2017) in targeted facilities. Facility Increase vaccination rates to > 60% for both pneumococcal pneumonia and hepatitis B Bibliography AARP 2009: Keenan T. Preventive Health Screenings among Midlife and Older Adults, interviews conducted for AARP by Woelfel Research, Inc. from December 2 to December 11, AARP Knowledge Management, February CDC, The Pink Book: Course Textbook 13 th Edition (2015), 7

8 CDC, Vaccine Information Statement Hepatitis B Vaccine, 2/2/2012, CDC. Vaccine Information Statement PVC Vaccine, 11/05/2015, Patel, Priti, Overcoming Barriers and Other How To s ; presented 10/21/2007. U.S. Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010 Appendices A. Inclusion letter and project agreement B. Patient Ambassador role description C. Centers for Medicare & Medicaid: Plan-Do-Study-Act and Template for QAPI D. Root Cause Analysis Tool 8

9 Appendix A: Inclusion Letter and Project Agreement To: Medical Directors, Nurse Managers, and Facility Administrators From: Deborah DeWalt, NW9 QID, Victoria Cash, NW9 ED Date: January 9 th, 2017 RE: 2017 Vaccination Goals: Increase Hepatitis B and Pneumococcal Pneumonia Vaccination Rates Quality Improvement Activity Project Background The Centers for Disease Control and Prevention (CDC) is advised by the Advisory Committee on Immunization Practices (ACIP) for the selection of vaccine preventable diseases and for the CDC director s approval. Immunizations are the most cost effective and best way to prevent getting a disease. Due to vaccinations some diseases are almost gone. Successful vaccination programs have helped to decrease the prevalence and eradicate many diseases. The CDC posts the recommendations for all vaccinations in the CDC s Morbidity and Mortality Weekly Report (MMWR). Two vaccines are the pneumococcal pneumonia and the hepatitis B. Approximately 18,000 patients die each year from pneumococcal disease and treatment with antibiotics are less effective due to the bacteria becoming drug resistant 7. Hepatitis B is a serious disease that affects the liver, with 2000 to 4000 patients dying from cirrhosis or liver cancer each year 8. For this project CMS has determined the need to improve vaccination rates for both pneumococcal pneumonia and hepatitis B. Quality Improvement Activity Description IPRO ESRD Networks will be implementing CMS designated activities with facilities chosen for this activity to increase rates of pneumococcal pneumonia and hepatitis B vaccinations at the facility level. Facilities will be provided with root cause analysis (RCA) templates that the Network will review with the project lead to develop a Plan Do Study Act (PDSA) cycle for improving rates of pneumococcal pneumonia and hepatitis B vaccinations. The project will be conducted beginning in January 2017, and will end September Facilities must increase their vaccination rate by a minimum of three percent for both vaccinations by September 2017 and facilities that do not meet the vaccination rate >60% will continue into the project for the next calendar year (2018). Your facility has been chosen to participate in this activity based on the facility rate of vaccination for pneumococcal pneumonia and hepatitis B from January 1st through December 31, Activities related to this activity include identifying a root cause analysis (RCA) for your facility s underperformance (see attached), and then creation of a corrective action plan based on that RCA to address these causes. Please be aware that communication about this QIA will be coming soon to those identified as representatives. Accurate contact information (including name, title, and address) is critical to ensure appropriate contact and complete information is received. Thank you in advance for your assistance and participation in this initiative. If you have any questions or comments about the QIA, your involvement, or future interventions please feel free to contact the Patient Services Department by at the addresses noted on the website. We look forward to working with you in this coming year s activities! 2017 Facility/Network Timeline of Activities January 2017 The Network will provide a notice of participation in this activity, as well as a template for evaluating the root cause analysis and providing a corrective action plan to overcome the low vaccination rates for pneumococcal pneumonia and hepatitis B. Facilities will be invited to attend a kick off webinar (date to be determined) to give over of project guidelines and documentation. 1 CDC. Vaccine Information Statement PVC Vaccine, 11/05/2015, 2 CDC, Vaccine Information Statement Hepatitis B Vaccine, 2/2/2012, 9

10 Facilities will use the provided RCA template to review both vaccination rates with the interdisciplinary team during QAPI meetings and return it by January 25, February 2017 The Network will contact each facility to review RCA and to establish a PDSA cycle for review of improvement activities. The Network will initiate the release of a monthly progress report. March April 2017 The Network will conduct a webinar at the end of April through May to share best practices identified based on RCA findings and to discuss successful interventions related to the RCA. May September 2017 Facilities will continue to implement interventions and provide a summary report to the Network on a monthly basis by or fax of any key observations discussed during monthly QAPI. The Network will provide a monthly progress report to all facilities in the project. The Network will continue to contact facilities who are not showing progress to goal to review corrective action plan and assist in PDSA discussions to create new interventions. 10

11 Vaccination QIA - Project AGREEMENT Page 1 Dear Provider, The Network shall achieve Centers for Medicare & Medicaid Services (CMS) goals through the development and implementation of quality improvement activities, such as the activity noted below. As directed by the Network governing bodies, 2017 performance goals have been set that every dialysis facility is expected to achieve. Please carefully review the notification letter and attached objectives for the Vaccination Quality Improvement Activity (QIA). After review, please complete the necessary fields, have the Project Lead, Facility Administrator/Nurse manager, and the Medical Director sign, and return to the Network office via at or by fax by January 25, 2017.**Please note, regardless of assigned Project Lead, Medical Director and Facility Administrator/Nurse Manager are responsible for ensuring completion of project objectives. In anticipation to your timely response, I thank you for your ongoing support and cooperation with the Network. If you have any questions or additional information is needed regarding these goals, please contact Deborah DeWalt, Director of Quality Improvement at ddewalt@nw9.esrd.net. Sincerely, Vicky Cash, MBA, BSN, RN Executive Director Deborah DeWalt Patient Services Director CC: Medical Director, Facility Administrator/Nurse Manager, Regional Contact 11

12 DUE 01/25/17 Vaccination QIA- Project AGREEMENT Page 2 January 2017 September 2017 The undersigned hereby agrees to participate and cooperate with the goals and activities, including quality improvement projects, as set forth by IPRO ESRD Network (42 CFR Part V772 (i) of Centers for Medicare & Medicaid Services (CMS) regulations). Facility Name (DBA): Project Lead Name: Medicare Provider # (CCN): Project Lead Title: Project Lead Signature: Project Lead Medical Director: Date: Medical Director s Signature: Medical Director Facility Administrator/Nurse Manager Name: Date: Facility Administrator/Nurse Manager Signature: Regional Director/Area Administrator: Regional Director/Area Administrator Phone: Patient Ambassador (see role description) Any changes to the above listed contacts must be reported to the Network and corrected in CROWNWeb within 5 business days to ensure continuity with project implementation and communications between the Network and Facility. Plans are reviewed periodically, and are subject to change based on the CMS Statement of Work (SOW). QUALITY IMPROVEMENT ACTIVITY Project Objective Increase pneumococcal and hepatitis B vaccinations at the facility level Primary Project Measures: o Pneumococcal pneumonia and hepatitis B vaccinations in CROWNWeb Primary Project Goals: o Increase pneumococcal pneumonia and hepatitis B vaccination rates at the facility level by a minimum of 3% Action Items/Facility Requirements o Perform Root Cause Analysis (RCA) (January l 2017) o Implement Interventions (January 2017 through September 2017) o Report on progress to Network (January 2017 through September 2017) INFORMATION MANAGEMENT/DATA REPORTING RELATED TO THIS PROJECT CROWNWeb (CW) Report clinical data 12

13 Appendix B: Patient Ambassador Dear Project Lead, Research and best practices have demonstrated that facilities with active participation of patients as members of the health care team achieve better clinical outcomes more readily. This year, the Network is requesting that each facility designate at least one patient, or preferably, one patient per shift to take the lead on special projects. We will provide training for these patients to supervise these programs in the clinic. Patients should be viewed as role models in the facility. A role model will display the ability to lead project activities and become the unofficial spokesman on the care team. In this role, the patient will: Provide contact information to the Network, Participate in educational and informational web conference presentations with the Network, and Review educational materials designed for patients in the target facilities and throughout the Network community. THE VACCINATION QUALITY IMPROVEMENT PROJECT REQUIRES EACH FACILITY TO NOMINATE A PATIENT AMBASSADOR. 13

14 Appendix C: Centers for Medicare & Medicaid: Plan-Do-Study-Act and Template for QAPI Network Information ESRD Network Number Network 9 ESRD Network Name Contract Number Facility Selection Facility Name Facility CCN Measure Targeted Baseline Results Improvement Goal IPRO End Stage Renal Network of the Ohio River Valley HHSM C Vaccinations 60% vaccination rate in HBV and PPV Criteria for Completion At re-measure September 2017 Root Cause Analysis Summary Names of facility staff involved in RCA Date RCA completed What underlying issues did facility staff identify as potential causes for poor performance related to vaccination rates? PDSA Cycle Describe the intervention to address the root cause(s). Intervention start date 14

15 Appendix D: Root Cause Analysis Tool 15