Lesson #7: Quality Assessment and Performance Improvement

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ESRD Update: Transitioning to New ESRD Conditions for Coverage Student Manual Lesson #7: Quality Assessment and Performance Improvement Learning Objectives At the conclusion of this lesson, you will

1 ESRD Update: Transitioning to New ESRD Conditions for Coverage Student Manual Lesson #7: Quality Assessment and Performance Improvement Learning Objectives At the conclusion of this lesson, you will be able to: Describe an effective data driven quality assessment & performance improvement (QAPI) program List measures that facilities should review & work to improve through QAPI Discuss how to survey for QAPI activities Centers for Medicare & Medicaid Services 337

2 Centers for Medicare & Medicaid Services 338

Bonnie Greenspan Judith Kari Show Me The Progress 1 Objectives At the end of this session, you will be able to: Describe an effective data driven quality assessment & performance improvement (QAPI)

3 Bonnie Greenspan Judith Kari Show Me The Progress 1 Objectives At the end of this session, you will be able to: Describe an effective data driven quality assessment & performance improvement (QAPI) program List measures that facilities should review & work to improve through QAPI Discuss how to survey for QAPI activities 2 V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team

4 V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. 4 Effective QAPI (V627) an ongoing program that achieves : Measurable improvement in health outcomes and Reduction of medical errors 5 Data-Driven QAPI (V627) Using indicators or performance measures associated with improved health outcomes and with identification and reduction of medical errors 6 340

5 Performance Measures (See MAT) (V629) Adequacy (V630) Nutrition (V631) Bone disease (V632) Anemia (V633)Vascular access (V634) Medical errors V635) Reuse (V636) Pt satisfaction (V637) Infection control Kt/V, URR Albumin, body weight PTH, Ca+, Phos Hgb, Ferritin Fistula, catheter rate Frequency of specific errors Adverse outcomes Survey scores Infections, vaccination status 7 Clicker Question Choose Your Favorite: 1. (V629) Adequacy 2. (V630) Nutrition 3. (V631) Bone disease 4. (V632) Anemia 5. (V633) Vascular access 6. (V634) Medical errors 7. (V635) Reuse 8. (V636) Patient satisfaction 9. (V637) Infection Control 8 Performance Measures Don t Blame Me You Picked Them 9 341

professional members of the interdisciplinary team. 10 Interdisciplinary Team: Show Me The Progress 11 professional members of the interdisciplinary team.

6 V626 QAPI Condition Statement (cont.) The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. 10 Interdisciplinary Team: Show Me The Progress 11 V626 QAPI Condition Statement (cont.) The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS

7 Monitoring Performance Improvement (V638) The facility must: Continuously monitor its performance Take actions that result in performance improvement Track to assure improvements are sustained over time 13 Prioritizing Improvement Activities (V639) Considerations in prioritization Prevalence of problem Severity of problem Impact on clinical outcomes Impact on patient safety 14 Immediate Correction Examples of serious health and safety threats: Unsafe water or dialysate Defective clinical equipment Unsafe reprocessing of dialyzers Epidemiological risks Insufficient number of competent staff to perform scheduled treatments: Preserve accesses Monitor patients Assure safe machine function

8 CMS Surveyor Tools for QAPI CMS will be working with The Renal Community/Networks Contractors for Dialysis Facility Reports & CROWNWeb To develop Surveyor Tools for QAPI 16 Clicker Question!!! Who is responsible for a facility s quality assurance and performance improvement program? A. The interdisciplinary team B. The medical director C. The governing body D. All of the above 17 Quality Assessment and Performance Improvement

9 Resources Centers for Medicare & Medicaid Services 345

10 Centers for Medicare & Medicaid Services 346

11 Phase III ESRD Clinical Performance Measures in effect April 1, 2008 Anemia Management Measure Description Assessment of Iron Stores - Facility Level Percentage of all adult (>=18 years old) hemodialysis or peritoneal dialysis patients prescribed an ESA at any time during the reporting period or who have a Hemoglobin <11.0 g/dl in at least one month of the reporting period for whom serum ferritin concentration AND either percent transferrin saturation or reticulocyte Hemoglobin content (CHr) are measured at least once in a three-month period for in-center hemodialysis patients, and at least twice during a six-month period for peritoneal dialysis patients and home hemodialysis patients. Hemoglobin control for ESA therapy - Facility Level Adult hemodialysis and peritoneal dialysis patients, with ESRD 3 months, who have received ESA therapy at any time during a 3 month reporting period AND have achieved a mean hemoglobin of g/dl for the 3 month reporting period. The hemoglobin value reported for the end of each month (end-of-month Hemoglobin) is used for the calculation. Monitoring hemoglobin levels below target minimum - Facility Level Hematocrit control for ESA therapy - Facility Level Adult hemodialysis and peritoneal dialysis patients, with ESRD > 3 months, who have a mean Hemoglobin <10.0 g/dl for a 3 month reporting period, irrespective of ESA use. The hemoglobin value reported for the end of each reporting month (end-of-month Hemoglobin) is used for the calculation. Adult hemodialysis and peritoneal dialysis patients, with ESRD 3 months, who have received ESA therapy at any time during a 3 month reporting period AND have achieved a mean hematocrit of 30 36% for the 3 month reporting period. The hematocrit value reported for the end of each month (endof-month Hematocrit) is used for the calculation. Monitoring hematocrit levels below target minimum - Facility Level Adult hemodialysis and peritoneal dialysis patients, with ESRD > 3 months, who have a mean Hematocrit <30% for a 3 month reporting period, irrespective of ESA use. The hematocrit value reported for the end of each month (end-of-month Hematocrit) is used for the calculation. 4/1/2008 Page 1 of 4 347

12 Phase III ESRD Clinical Performance Measures in effect April 1, 2008 Hemodialysis Adequacy Measure Description Hemodialysis Adequacy- Monthly measurement of delivered dose Percentage of all adult (>= 18 years old) HD patients in the sample for analyses with documented monthly adequacy measurements (spkt/v) or its components in the calendar month Method of Measurement of Delivered Hemodialysis Dose Percentage of all adult (>18 years old) in-center HD patients in the sample for analyses for whom delivered HD dose was calculated using UKM or Daugirdas II during the reporting period and for whom the frequency of HD per week is specified. Minimum delivered hemodialysis dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 6 months or greater. Facility Level Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 6 months or more and dialyzing thrice weekly whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spkt/v >= 1.2 during the reporting period. Minimum delivered hemodialysis dose for ESRD hemodialysis patients undergoing dialytic treatment for a period of 90 days or greater. Facility Level Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spkt/v >= 1.2 during the reporting period. Percentage of the facility s hemodialysis patients with a urea reduction ratio (URR) of 65% or greater in the calendar year Facility Level Number of eligible Medicare hemodialysis patients at the facility during the calendar year with a median URR value of 65% or higher. Peritoneal Dialysis Adequacy Measurement of total Solute Clearance at regular intervals Facility Level Measure Description Percentage of all adult (>= 18 years old) peritoneal dialysis patients with total solute clearance for urea (endogenous residual renal urea clearance & dialytic) measured at least once in a four month time period. 4/1/2008 Page 2 of 4 348

13 Phase III ESRD Clinical Performance Measures in effect April 1, 2008 Delivered Dose of peritoneal dialysis above the minimum of 1.7 Facility Level Percentage of all adult (>= 18 years old) peritoneal dialysis patients whose delivered peritoneal dialysis dose was a weekly Kt/Vurea of at least 1.7 (dialytic + residual) during the four month reporting period. Mineral Metabolism Measurement of Serum Calcium Concentration - Facility Level Measurement of Serum Phosphorus Concentration Facility Level Measure Description Percentage of all adult (>= 18 years of age) peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum calcium measured at least once within month Percentage of all adult (>= 18 years of age) peritoneal dialysis and hemodialysis patients included in the sample for analysis with serum phosphorus measured at least once within month. Vascular Access Minimizing use of catheters as Chronic Dialysis Access Facility Level Measure Description Percentage of patients on maintenance hemodialysis during the last HD treatment of reporting period with a chronic catheter continuously for 90 days or longer prior to the last hemodialysis session Maximizing Placement of Arterial Venous Fistula (AVF) - Facility Level Functional Autogenous AV Fistual Access or referral to vascular surgeon for placement - Clinician Level Percentage of patients on maintenance hemodialysis during the last HD treatment of month using an autogenous AV fistula with two needles Percentage of all ESRD patients aged 18 years and older receiving hemodialysis during the 12 month reporting year who have a functional autogenous AV fistula (defined as two needles used) or do not have such a fistula but have been seen by a vascular surgeon for evaluation for permanent access at least once during the reporting year. Catheter Vascular Access and referred to vascular for evaluation for a permanent access - Clinician Level Percentage of all ESRD patients aged 18 years and older receiving hemodialysis during the 12 month reporting year with a catheter after 90 days on dialysis who are seen by a vascular surgeon for evaluation for permanent access at least once during the 12 month reporting period. Decision-making by Surgeon to Maximize Placement of Autogenous Arterial Venous Fistula - Clinician Level Percentage of patients with advanced chronic disease (CKD4 or 5)or end-stage renal disease (ESRD) undergoing open surgical implantation of permanent hemodialysis access who receive an autogenous arteriovenous fistula (AVF). 4/1/2008 Page 3 of 4 349

14 Phase III ESRD Clinical Performance Measures in effect April 1, 2008 Influenza Vaccination Influenza Immunization Clinician Level Measure Description Percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis who received the influenza immunization during the flu season (September through February) Influenza Vaccination in the ESRD Population - Facility Level Percentage of all ESRD patients aged 18 years and older receiving hemodialysis and peritoneal dialysis during the flu season (October 1 - March 31) who receive an influenza vaccination during the October 1 - March 31 reporting period. Patient Education, Perception of Care, and Quality of Life Patient Education Awareness Facility Level Measure Description Percentage of all ESRD patients 18 years and older with documentation regarding a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no treatment). Measured once a year. Patient Education Awareness Clinician Level Percentage of all ESRD patients 18 years and older with documentation regarding a discussion of renal replacement therapy modalities (including hemodialysis, peritoneal dialysis, home hemodialysis, transplants and identification of potential living donors, and no treatment). Measured once a year. CAHPS In-Center Hemodialysis Survey Facility Level Assessment of Health-related Quality of Life (Physical & Mental Functioning) Facility Level 57 question survey that assesses patients' experience with In-Center Hemodialysis Percentage of dialysis patients who receive a quality of life assessment using the KDQOL-36 (36- question survey that assesses patients' functioning and well-being) at least once per year. Patient Survival Facility Patient Survival Classification (based of Standardized Mortality Ratio) Facility Level Measure Description Risk-adjusted standardized mortality ratio for dialysis facility patients 4/1/2008 Page 4 of 4 350

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A provider s guide to encouraging arteriovenous fistula (AVF) prevalence in renal dialysis patients The best vascular access that can be offered patients is a native arteriovenous fistula (AVF).

Network 11, State Survey Agencies, and Providers have formed a partnership to work toward improving the rate of fistula placement.

17 A provider s guide to encouraging arteriovenous fistula (AVF) prevalence in renal dialysis patients The best vascular access that can be offered patients is a native arteriovenous fistula (AVF). Of all the types of vascular access available, fistulas are associated with the lowest failure and complication rates, and provide for superior bloodflow rates which allow for more efficient dialysis. Network 11, State Survey Agencies, and Providers have formed a partnership to work toward improving the rate of fistula placement. This outline is provided to help you better prepare for the future expectations of your facility. Please review this with your facility Medical Director and your staff to better prepare your staff for future Medicare surveys. Thank you for your partnership on these very important Fistula First initiatives For additional resources, contact: www. fistulafirst.org fistula_first.asp or Renal Network 11 at: (651) info@nw11.esrd.net Prepared by the Upper Midwest Fistula First Coalition May reprint with permission by the Upper Midwest Fistula First Coalition A Provider s Guide Preparing for the Vascular Access Portion of your Medicare Survey 353

18 Focus on the Fistula Plan The following are areas that may be reviewed during a Medicare survey. This has been assembled to help your facility prepare for a Medicare survey with a focus on vascular access. Pre-survey Activities: Surveyors may review the facility specific data report and contact the Renal Network 11 for current information regarding your facility s vascular access rates. Entrance Conference: Surveyors may ask for the patient roster which includes the type of vascular access. Surveyors may review with the facility questions from the off-site specific data report or information from the Network to verify current patient access data. Surveyors may ask the facility to collect all quality assurance information for review regarding access monitoring, goals, infection rates,etc. Tour and Direct Observation: Surveyors may observe the staff process of assessing and cannulating vascular access. Surveyors may observe the staff process of access assessment. Sample Selection: Surveyors will select at least a 10% sample for record review, which may include patients with catheters, grafts, and fistulas. Patient Interviews Surveyors may ask patients: What have they been told and what is their understanding of their options/risks/benefits of various kinds of vascular access? How long have they been on dialysis? Why they have the access type observed? Has anyone talked with them about their access care? Staff Interviews Surveyors may ask: The nursing staff how patients are informed of vascular access options. The Medical Director how the facility addresses vascular access. The Medical Director to describe cannulation training for staff and patients. The Medical Director to describe the access monitoring system. Clinical Record Review: Surveyors may check for documentation of patients awareness of options, choices and education related to risks/benefits of various vascular access types. Review Personnel Records: Surveyors may look in the staff training history to see if there are specific indications of specialized training in cannulation, assessing sites, maturing fistulas, and the care of new fistulas. Surveyors may look to see evidence of ongoing evaluation of skills. Quality Assurance Surveyors may: Look for Vascular Access monitoring systems. Look for trends: tracking percent of each type of access and infection rate. Look for identified goals for vascular access management and action toward those goals. Look to identify how many conversions took place in the last 12 months (i.e. catheter/graft to fistula). Look to identify systems of consultation with vascular surgeons and how the facility communicates and consults with surgeons. 354

NATIONAL QUALITY FORUM Renal EM Submitted Measures

NATIONAL QUALITY FORUM Renal EM Submitted Measures Measure ID/ Title Measure Description Measure Steward Topic Area #1662 Percentage of patients aged 18 years and older with a diagnosis of CKD ACE/ARB