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2009 ESRD Network of Texas, Inc.

  Network Coordinating Council
           Meeting
CHAIRMAN’S REPORT
   Richard Gibney, MD
           Gibney

Network Elections
Quality Improvement
A Pause to Reflect

     Supporting Quality Care
NOMINATING COMMITTEE 09-10
                     09-

Melvin Laski, Lubbock
Richard Gibney MD Waco
        Gibney, MD,
Robert Hootkins, MD, Austin
Cleve Collins, MD, San Antonio
Tom Lowery MD Tyler
     Lowery, MD,
Slate of Officers

Melvin Laski, MD, Chairman
Manny Alvarez, MD, Vice Chairman
Larry McGowan, Treasurer
Amy Hackney, Secretary
Richard Gibney, MD
  Immediate Past Chairman
Ruben Velez, MD MRB Chair
       Velez MD,
Laura Yates, RN, At Large
Charles Orji, MD, At Large
Leigh Anne Tanzenburger, At Large


   09-
   09-10 EXECUTIVE COMMITTEE
Network Coordinating Co ncil
Net o k Coo dinating Council

        Election
Words on Quality
Q
     QUALITY IMPROVEMENT
URGENCY TO CHANGE:

  Improve quality of care (↓harm)
                          (↓harm).
All / Patients & family benefit
Win  Staff (RN, PCT, SW, Dietitian, Physician

   ↓ Mortality, improve quality indicators.
  Evidence based medicine, best practices, more efficient time,
                         ,      p        ,                    ,
  patient flow.
  ↓Chance of liability.
  Our reputation (not national average or less).
  Transparency good!
  It i noble & uplifting to be the best at helping our fellow man.
     is bl       lifti t b th b t t h l i              f ll
Q
    QUALITY IMPROVEMENT

“The problem with life is,
     p                   ,
 there is no SCARY music.”

 -- Robin Williams



 ↓Mortality, ↓Patients Harmed.
Q
    QUALITY IMPROVEMENT
DATA USE:

  Right things easy  BIG GOALS!
  Bad things hard /

  Simple & visual.

  No denominator.
  N d     i t

  “Hope is not a strategy.”

  “Complexity is the enemy of reliability.”

  Protocols, processes,
  Protocols processes systems flow (orders diagnosis
                                   (orders, diagnosis,
  & treatment.)
WE HAVE BEEN CALLED TO A MINISTRY,

WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON’S LIFE
                                                   LIFE;

            A REAL AND TREASURED PRIVILEGE.

                                     -- James Reinertsen, M.D.
                                        September, 2008
LOAVES AND FISHES
This is not the age of
information.
This is not
the age of information.

Forget the news,
   g           ,
and the radio,
and the blurred screen.

This is the time of loaves
and fishes.

People are hungry,
and one good word is bread
         g
for a thousand.
                 --David Whyte
Report from the Executive
         Director

Glenda Harbert, RN, CNN, CPHQ
MISSION Statement

The ESRD Network of Texas, Inc.
supports quality dialysis & kidney
transplant healthcare th
t     l t h lth       through patient
                             h ti t
services, education, quality
                     q     y
improvement & data exchange.
                         2003
Topics
DSHS Referrals & Rules
Network Growth
Network Activities
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
                  DSHS C
                       Council meeting on
                              il   ti
 30 day comment period after the proposed
 rules are published
   l          bli h d
 No decision yet if a public comment hearing
 will be held during the 30 day comment period
DSHS responds to each comment submitted
during the comment period – the comment is
either accepted and the suggested change
made,
made or it is not and why

After
Aft comment period, fi l rule preamble
               t    i d final l         bl
and final rules go to HHSC for final approval

After approval, the final rules are published
and become effective 30 days after
publication
      www.dshs.tx.us/hfp/rules.shtm
      www dshs tx us/hfp/rules shtm
DSHS Referral Update
Number of Cases & Levels
Common Themes
Unsafe Infection Control Practices
   Poor hand washing practices
   Inappropriate use of Personal Protective Equipment
   (PPE)
   Not disinfecting surfaces
Failure to implement Quality Assessment and
Performance Improvement (QAPI)
Patient Safety Concerns
   Lack of patient assessments (pre, during & post)
   Disabling machine alarms
Common Themes
Vascular Access Outliers
  High Catheter Rate
  Low AVF Rate
Unsafe Physical Environment
  Dirty floors
  Broken Tiles, etc.
Water Treatment Practices
  Not testing properly
  Lack of staff knowledge
  Unsafe Reuse practices
Communication Issues
PCT’s not reporting critical treatment
data/events to nurses:
  Failure to report
    Hyper & Hypo tension pre, during, and post dialysis
    treatments
  Initiating Sodium Profiling with ↑ BP
  Failure to:
    obtain accurate weights
    identify wet transducers
    communicate “Reportable Parameters” to physician or
    nurse
Serious Situations
Patient deaths attributed to nursing practice
issues
Phlebotomy of 1 liter of blood every
treatment X 3 treatments
Hep
H B positive (+) conversion then converted
           ii ( )            i     h           d
to negative (-) with pt. left in Isolation Room
for extended period
Initiating dialysis when water treatment out
of parameters
Serious Situations
Use non-standard dialysate without
appropriate monitoring
 pp p                  g
Failure to recognize, report and track
Adverse Events
2008 Network #14 Growth &
Trends
•CMS Certified Facilities
• Facility Ownership
• Growth in Patient Census
• Patients Transplanted
Network Growth
      Total Number of Texas Dialysis Facilities




CMS Annual Facility Survey Data
The ESRD Network of Texas, Inc.
Facility Ownership in Texas




                              26
2008 Texas Facility Ownership (%)




                                    27
Total Number of Texas Patients
(Includes Home & In-Center HD and PD Patients)
                 In-
Total Transplants by Donor Type




                                  29
2004-
                     2004-2007
        Standardized Transplantation Ratio
          a da d d a p a a o a o
                      (STR)




UM KECC DFR report
2007
       Percent Patients (<70 years old) on
                a       ( 0 y a o d) o
               Transplant Waitlist




UM KECC DFR report
2007
                                      Percent Patients on the
                                       Waitlist by Subgroup
Pe         S                aitlist
 ercent of Subgroup on the Wa
Distribution of Percent of Texas Facility
          Patients on Waitlist 2007




UM KECC DFR report
Paired donation
Matches one incompatible donor/recipient
pair to another pair with a complimentary
incompatibility,
incompatibility

so that the donor of the first pair gives to
                               p g
the recipient of the second, and vice
versa.
Potential Donations
                         5000
                       anges




                         4000
Number of Possible Excha




                                       •100 donor - recipient pairs generates
                                          4,950 potential paired exchanges
                         3000


                         2000
     r




                         1000


                               0
                                   1     11    21    31    41     51    61      71   81   91   101
                                                           Number of Pairs
Alliance for Paired Donation
Composed of 63 transplant centers in
22 states.
1st year APD facilitated 19 paired
exchanges
List of Texas Participating Centers
(18)
www.paireddonation.org
Paired Donation Network
Includes over 80 kidney transplant programs
in
i 23 states that are organized in five regional
       t t th t           i d i fi        i   l
consortia.
14 p i ed donor transplants have been done
   paired dono t n pl nt h e
within the PDN system since October 08.
Texas – 2 centers
  North Austin Medical Center
  Memorial Hermann Renal Transplant Center
  http://www.paireddonationnetwork.org/
Activities of the Network
Quality Improvement
Outreach
  TEEC & Disaster preparedness
  Patient & Provider Technical Assistance &
  Education
  Involuntary Discharge
Information Management
Quality Improvement
Lab data Collection
Quality Improvement Projects
  Home Sweet Home
  Quality of Care Concerns & CPM’s
                             CPM s
    Vascular Access Improvement Projects
    Severe Anemia
    2 year outliers for clinical labs
Patient Services and Outreach
What is
         Wh t i TEEC?
The mission of
TEEC is to ensure a
coordinated
preparedness, plan,
response and
   p
recovery to
emergency events
affecting th T
 ff ti the Texas
ESRD community.
The  State Of  E In  Sexas
Important Lessons Learned
 Independent facilities must pre-plan for
 backup dialysis with another provider

 Patients should be encouraged to evacuate

 Any patient with limited mobility, support
                          mobility
 systems and or transportation MUST be
 registered for evacuation with 211

 Telling patients to go the hospital for dialysis
 is NOT a disaster plan!
Involuntary Discharge
                     54

                          46
           44
                40

32
      31




                               < 0.15% of
                               total
                               patients
Monitoring & Profiling Complaints
           by Facility
Percent of total Facilities with
         Complaints

                           1 Complaint 14.7% 

                                  2 Complaints 1.5% 


                                     3 Complaints 0.02% 
                                     3 Complaints 0 02% 




            None 83.78% 


                                >3 Complaints 0.0% 
Booklet Test

Fall 2008
6 facilities- El Paso
  facilities-    Paso,
Angleton, Houston,
Tyler, Lubbock
Tyler Lubbock,
McAllen
55 patients
      ti t                              In English and Spanish
   http://www.esrdnetwork.org/patients/education/resources.asp
Test Method
9 volunteer RD’s were asked to participate
 – 6 completed the test


RD’s were asked to select 9 patients (if possible) with the
following characteristics to be representative of NW 14 patient
        g                         p                      p
population
 – 43% Hispanic ethnicity n= 3
 – 57% Non-Hispanic White= 4 including 1 other race, such as
    Asian if possible
 – 30.5% Black= 2


Of the 9 patients include at least
   2 Non–readers
   1 English speaking
   1 Spanish speaking
Ask Me Three Methodology*
Selected readers were given the booklet to
readd
Non readers had the booklet read to them
in either English or Spanish
After the patient read the booklet (or had it
          p                        (
read to them) RD’s were asked to explain
to patient :
   p

                     * National Patient Safety Foundation
Non Blaming, Non Shaming
     Blaming
“We are testing how well we did
  We
writing this booklet so patients can
understand what it says. I would
   d t d h t                    ld
like to ask you a few questions to
see how well we did.”
Not:
  Do you understand?
  Do
  D you hhave any questions?
                      ti ?
The RD then asked 3 simple questions
and recorded the answers awarding 1
point for each correct answer accepting
multiple answers

A other category was i l d d for
   th     t          included f
answers the RD deemed correct that
were not one of th pre-selected
        t      f the      l t d
answers
Patient Scores
Total score of > 4 considered booklet
effective
50 of 55 > 4 (91%)
Of the 5 that did not score at least 4
 – 1 Hispanic white spanish speaking non-
                                       non-
   reader
 – 3 Non Hispanic white English reader*

 – 1 African American English reader
                               reader*

*Although it is not known, it is possible these patients were
       g                 ,       p              p
  marginal readers. It is common for adult poor readers or
  non-
  non-readers to deny their literacy status.
Average Score by Group


                                Hispanic         Hispanic     Non        Non
                        Hispanic White Hispanic White       Hispanic   Hispanic
              Black A/A  White    ENG.    White Spanish      White      White
 Black A/A    ENG. non    ENG.    non    Spanish   non        ENG.     Spanish
ENG. reader    reader    reader  reader reader    reader     reader     reader
   N=10          N=1      N=10    N=2      N=5     N=7        N=15       N=3




   5.5           9        6.3       5      5.6     4.9        4.8        8.3
Question #1: What is the main problem?
        Correct answer= thi t
        C     t          thirst
What are things I can do about it?
   (strategies to control thirst)
                           Percent responding
                           Percent responding
                    Other 
             approved by RD                     Use smaller 
             as correct, 38%                     glass , 45%
   if Diabetic: 
Control blood 
 sugar , 22%
                           Use                         Suck on 
                                                       S k
                   hard candy or                  ice, 51%
                    gum , 44%



                                                               Don't 
                                                       eat processed 
                                                       eat processed
                                                        meats , 25%
Why is this important for me?

                       Percent responding  
                       Percent responding
                            other , 9         less swelling, 35
  not as thirsty, 29



         less sob, 40
                                          less fluid gain, 
                                                 64
                       better for my 
                         heart, 60
Conclusions
The booklet effectively educated patients
of several demographics regarding:
 f       ld          hi       di
–   The main topic- with 95% answering thirst
    correctly
–   Strategies to control thirst
      22 51%
      22-51% cited >1 of 5 answers determined in
      advance to be correct
      38% cited another answer that the RD approved
      as correct
      Suck on ice was the strategy scoring the highest
      (51%)
Conclusions, continued
–   Importance to them personally
      29 64%
      29-64% cited >1 of 5 answers determined
      in advance to be correct
      Less fluid gain was the reason scoring the
                 g                          g
      highest (64%)
      Better for my heart second highest (60%)
                   y               g      (    )
      9% cited another answer that the RD
      approved as correct
Why do all that for a booklet
  y
  everyone likes & uses?
Need to show effectiveness of outreach to
CMS
Learning new methods to address
  Health Literacy issues
  Demonstrating effectiveness
Health Literacy: A Prescription to End
              Confusion.

90 million US adults: literacy skills below high
school level
Adults with limited literacy:
  less knowledge of disease management & health
  promoting behaviors
          i b h i
  report poorer health status
  less likely to use preventive services
            y        p
  higher hospitalization rates & emergency service
  use
  less adherence
>300 studies show health-related materials far
exceed average reading ability of US adults
                      Institute of Medicine, 2004
                                   Medicine
Health Literacy of American Adults




                        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
capacity to;
  p    y ;
  obtain,
  process, and
  understand
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 had difficulty understanding at
least one of the five instructions.
“What Did the Doctor Say?”*
                           y
Recommends making plain language a
 “universal precaution” in all patient
 encounters



                     *Improving Health Literacy to Protect Patient
                     Safety- Joint Commission
What is plain language?
       • Plain language is communication that an audience can
         understand the first time they read or hear it.
                                                     it
What

       • The concept of using plain language is closely related to
         the concept of health literacy.
Why
  y

       • Clear communication is critical to successful health care.
                                                              care
How
Watch for more information on
Health Literacy and Patient Education
What happened to Crown Web?



•Phase I- Pilot Project with 4 Networks & 8
Facilities
F iliti
•Phase II ? Spring or Summer 09
•Full Implementation ??
 F ll I l       t ti
•For more Information- Special Session
Saturday Aft
S t d Afternoon
Thank you for all that you do

     gharbert@nw14.esrd.net
          469-916-
          469-916-3801
Report from
Medical Review Board (MRB)
         Chairman


 Robert Hootkins MD, PhD, FACP, FASN
 R b t H tki MD PhD FACP
My Assignment Today!
   y     g          y

Review geographic representation
and functions of MRB


Share current NW #14 clinical
indicator data

Closing thoughts as outgoing
“lame duck Chairman
 lame duck”
MRB Functions
Evaluate quality and appropriateness of care
delivered to ESRD patients in Texas

Propose Corrective Action Plans (CAP) for dialysis
units with Level 2-3 deficiencies to Texas
                 2-
Department of State Health Services (DSHS)
Analyze NW #14 data and recommend clinical
outcome profiling cut-points
                  cut-

Serve as primary advisory panel to Network to
promote improved patient care and safety
through QI activities
Utilize NW #14 data to identify Network-wide
                              y Network-
improvement opportunities
Current Geographic
                           Representation of MRB
                                               Ruben Velez, MD
                                               Camille May, RN
                                               Ingemar Davidson, MD
                                               I       D id
 Jennie Lang House, RD                         Trish White, RN
                                               Mary Beth Callahan, SW
                                               Dianne Morgan
                                                 a e o ga

                                                    James Cotton, MD

                                                     Mohan Narayan, MD
                                                  Stuart Goldstein ,MD
 Robert Hootkins, MD                              Donald Molony, MD
 Deborah Heinrich, RN                             Jane Louis, RD
                                                  Jacqueline Lappin, MD
                                                  J      li L     i
                    Denise Hart, MD
                    Mazeen Arar, MD
                           Arar,
                    Joyce Hernandez, SW
                      y              ,      Clyde Rutherford, MD
                                                  Rutherford
                    Anna Gonzalez
                    Navid Saigal, MD
                          Saigal,         Kaylenne Duran, RN
The ESRD Network of Texas, Inc.
Information on
 Data & Projects
ESRD Network of Texas, Inc.
Comparative Clinical Indicator Data used by NW #14
                     Mandating                     Comparative
Data Collection                  Sample Size                            Use
                    Organization                    Data Level
                                                      Network
   Clinical                         Random                           Identify
                                                      and U.S.
 Performance            CMS         Sample                            NW QI
                                                     (No Facility
Measures (CPM)                      Patients                         Projects
                                                    Specific Data)

   Quality of                       100% of          Facility,       Identify
   Care(QOC)        Network #14      eligible      Network and        outlier
Indicator Project                   patients           U.S.          facilities

                                                     Facility,        Identify
                                    100% of
  Fistula First         CMS                        Network and       VA outlier
                                    patients
                                                       U.S.           facilities

                                                                       Data
                                    All facility     Facility,
                                                                     posted on
                                  patients with    Network and
 Annual Dialysis                                                      DFC and
                        CMS       URR and ESA          U.S.
 Facility Report                                                      used by
                                    Medicare
                                                                       State
                                  Billing Claims   SMR, SHR, STR
                                                                     Surveyors
Hemodialysis
 Adequacy
Percent of Patients
                       with URR > 65% - CPM
                 94        90%                                                    89%
                 92
                      90   90   90   90   90   90   90
                 90                                      89   89   89   89   89   89
 % of Patients




                                                                                       88   88   88
                 88                                                                                   87

                 86                                                                                        85
      P




                 84                                                                                             83

                 82
                 80
                 78
                 76
                      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
                        with Kt/V > 1.2 - CPM
                 93%
                  94                                              91%
                       93 93 93 93 93 93
                  93
                                           92 92 92 92 92
                  92
                                                             91 91 91
                  91
 % of Patients




                                                                        90 90 90
                  90
                                                                                   89
                  89
      P




                  88
                                                                                        87
                  87
                  86
                  85
                  84
                       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%


95% of TX HD facilities (N= 391) met or
exceeded th MRB quality cut-point!
     d d the           lit cut- i t!
                             t

What about the 5% of TX facilities (N=19) that
didn’t
did ’ meet the cut point?
            h        i
  14 facilities     71-
                    71-80% of patients had a URR > 65%
  3 facilities     61-
                   61-70% of patients had a URR > 65%
  1 facility      51-
                  51-60% of patients had a URR > 65%
  1 facility      0-10% of patients had a URR > 65%
Hemodialysis
Anemia Management
Percent of Patients
                           with HGB < 10.0 - CPM
                  9
                                                                                                 8
                  8                                         5%
                               5%                                                   7   7   7
                  7
                                                                        6   6   6
  % of Patients




                  6
                                        5   5   5   5   5   5   5   5
                  5
                           4   4    4
       P




                  4
                      3
                  3
                  2
                  1
                  0
                      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
                           with HGB > 11.0 - CPM
                                86%
                 88
                      86                             82%
                 86        85
                                84 84
                 84                     83 83 83
 % of Patients




                                                   82 82 82 82
                 82                                              81 81 81
                                                                            80 80 80 80
                 80
      P




                 78                                                                       77

                 76
                 74
                 72
                      14 1 17 18 3         7 15 11 US 16 12 5       6 10 4     8   9 13 2

                                                      Network

The ESRD Network of Texas, Inc.
Percent of Patients
                       with HGB 11.0-12.0 - CPM
                                11.0-
                       44%
                  50                                   39%
                       45 44
                  45           42 42 42 42 41 41
                                                 40 39 39
                  40                                      38 37 37 37
                                                                      36 36
  % of Patients




                  35                                                           33 32

                  30
                  25
       P




                  20
                  15
                  10
                   5
                   0
                        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.
MRB Quality of Care Cut Point
                             Cut-Point
for HD Severe Anemia Management (2007 data)
  Less than 11% of facility patients have a Hemoglobin < 10.0


 94% of TX HD facilities (N=413) met or exceeded
 the MRB quality cut-point!
                 cut-

 What about the 6% of TX facilities (N=26) that
 didn’t meet the cut point for this Hgb range?
    23 facilities     11-
                      11-20 % of patients with Hemoglobin < 10.0
    1 facility      21-30%
                    21-30% of patients with Hemoglobin < 10.0
    1 facility      41-50% of patients with Hemoglobin < 10.00
                    41-
    1 facility      91-100%
                    91-100% of patients with Hemoglobin < 10.0
                                                          10 0
MRB Quality of Care Cut-Point
 for HD Anemia Management (2007 data)
         More than 70% of facility patients have a
       Hemoglobin between > 10 0 and < 13 0 gm/dl
       H     l bi b          10.0 d 13.0          /dl

90% of TX HD facilities (N 370) met or exceeded
                        (N=
the MRB quality cut-point!
                cut-

What about the 10% of TX facilities (N=43) that
didn’t meet the cut point for this Hgb range?
  30 facilities     60.1-
                    60.1-70% of patients > 10.0 and < 13.0 gm/dl
  8 facilities      50.1
                    50.1-60% of patients > 10.0 and < 13.0 gm/dl
  4 facility      40.1-
                  40.1-50% of patients > 10.0 and < 13.0 gm/dl
  1 facility      0-10% of patients > 10.0 and < 13.0 gm/dl
Hemodialysis
Bone and Mineral
   Metabolism
Percent of Patients
                 with Phosphorus 3.5-5.5 - CPM
                                  3.5-
                                                                                          58%
                 70                                      52%

                 60                                                                        57 58
                                                                          54 55   55 56
                                            51 51 52   52 52   53 53 54
                                    50 51
                           48 49
                 50
 % of Patients




                      45

                 40
      P




                 30

                 20
                 10

                  0
                      6    7   16
                                6   5   8   13 17
                                             3      9 11 US 3 15 10 12
                                                               5 0           1 18 2
                                                                                8          4 14

                                                       Network
The ESRD Network of Texas, Inc.
Peritoneal Dialysis
     Adequacy
Percent of PD Patients
                            with Kt/V ≥ 1.7 - QOC
                                  2006                 2007
                      100
                       95                91.1   89.9
                       90
                       85
               ents




                       80
                       75
      % of Patie




                       70
                       65
                       60
                       55
                       50
                       45
                       40

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


75% of TX PD facilities (N= 84) met or exceeded
the MRB quality cut-point!
th         lit cut- i t!
                  t

What about the 25% of TX facilities (N=28) that
didn’t
did ’ meet the cut point?
            h        i
  18 facilities     71-
                    71-80% of patients met Kt/V > 1.7
  2 facilities      61-
                    61-70% of patients met Kt/V > 1 7
                                                  1.7
  1 facility      51-
                  51-60% of patients met Kt/V > 1.7
  7 facilities     0-50% of patients met Kt/V > 1.7
Peritoneal Dialysis
Anemia Management
Percent of PD Patients with
                    HGB < 10 0 - QOC
                            10.0




The ESRD Network of Texas, Inc.
Percent of PD Patients
                        with HGB ≥ 11 0 - QOC
                         ith        11.0
                   90
                        2000        2001        2002   2003
                   85   2004        2005        2006   2007
                                                                 81.9
                                                          80.4
                   80                           79.1                    78.3
          tients




                                         77.1
   % of Pat




                   75             73.8
                                  73 8

                        69.2
                   70

                   65

                   60
The ESRD Network of Texas, Inc.
Percent of PD Patients
                    with TSAT ≥ 20% - QOC
                     ith




The ESRD Network of Texas, Inc.
MRB Quality of Care Cut Point
                             Cut-Point
for PD Severe Anemia Management (2007 data)
  Less than 11% of facility patients have a Hemoglobin < 10.0


 77% of TX PD f iliti (N=77) met or exceeded the
      f        facilities (N 77) t       d d th
 MRB quality cut-point!
             cut-

 What b t th
 Wh t about the 23% of TX facilities (N=26) that
                        f    f iliti (N 26) th t
 didn’t meet the cut point for this Hgb range?
    14 facilities    11-
                     11-20 % of patients with Hemoglobin < 10.0
    6 facilities    21-30%
                    21-30% of patients with Hemoglobin < 10.0
    6 facilities    41-
                    41-50% of patients with Hemoglobin < 10.0
MRB Quality of Care Cut-Point
 for PD Anemia Management (2007 data)
         More than 70% of facility patients have a
       Hemoglobin between > 10 0 and < 13 0 gm/dl
       H     l bi b          10.0 d 13.0          /dl

66% of TX PD facilities (N=77) met or exceeded the
MRB quality cut-point!
            cut-

What about the 34% of TX facilities (N=40) that
didn’t meet the cut point for this Hgb range?
  19 facilities    60.1-
                   60.1-70% of patients > 10.0 and < 13.0 gm/dl
  6 facilities    50.1
                  50.1-60% of patients > 10.0 and < 13.0 gm/dl
  9 facilities    40.1-
                  40.1-50% of patients > 10.0 and < 13.0 gm/dl
  6 facilities    0-40% of patients > 10 0 and < 13 0 gm/dl
                                      10.0       13.0
Peritoneal Dialysis
     Albumin
Percent of PD Patients
                      with ALB ≥ 4 0/3 7 - QOC
                       ith       4.0/3.7
                 36
                                                 2000   2001     2002      2003
                 32
                                                 2004   2005     2006      2007
                                  27.4
                 28                      24.8
                                         24 8
                                                23.0
       atients




                 24                                              21.3
                                                          20.3          20.6
                 20
 % of Pa




                 16
                 12
                 8
                 4
                 0
The ESRD Network of Texas, Inc.
Vascular Access
 Management
AVF Utilization in the U.S.
                         November 2008
                70   64                     51.4%         50.5%

                60        57 57 56
                                   55 55
                                           52 51 51 51 51 50 50 50
                                                                   49 48 48 47
                50                                                             47
  Percent AVF




                40
                30
                20
                10
                0
                     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
                       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 prevalent AVFs
                                                  Assuming Equal Growth each Month

           52.8%

                            Where we need to be       Where we are/were                                         52.0%
           52.0%                                                                                        51.8%
                                                                                                51.5%

                                                                                  50.9% 51.2%
           51.2%                                                          50.6%
                                                                  50.3%
AVF Rate
    R




           50.4%                                          50.0%
                                                  49.7%                           50.5%
                                                                          50.4%
           49.6%                         49.4%       49.9%
                                   49.1% 49.6% 49.8%
                                          9 6%             50.0%
                           48.8%
           48.8%   48.5%
                                   48.8%
                   48.5% 48.6%
           48.0%
                   Mar-08 Apr-08 May-08 Jun-08
                   M 08 A 08 M 08 J         08    Jul-08 Aug-08 S
                                                  J l 08 A   08 Sep-08 O t 08 N 08 D 08 J
                                                                    08 Oct-08 Nov-08 Dec-08 Jan-09 F b 09 M 09
                                                                                                09 Feb-09 Mar-09
                                                                  Month
Percent of Prevalent Patients
                     with Catheter (with/without AVF or AVG,
                        regardless of duration of use) - CPM
                                                  use)

                    40
                                                   27%
                                                                                       34
                    35
                                                                   31 31 31 32 32 32
                          21%
                    30                         27 27 27 28 28 28
    % of Patients




                                    24 24 25
                    25           23
                         21 21
                    20
         P




                    15
                    10
                     5
                     0
                         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
                      with Catheter - CPM
                 30

                 25                                     24
                                                  23
                                          21                    21
 % of Patients




                 20               19
                       17

                 15

                 10

                 5

                 0
                      2002        2003   2004    2005   2006   2007

                                          Network 14
The ESRD Network of Texas, Inc.
September 2008

                                              Chart 2: Prevalent Texas Patients With Catheter Only

                                     Oct 2003         Oct 2004         Sep 2005    Sep 2006         Sep 2007      Mar 2008        Sep 2008
                                12
                         ents




                                                                                                     9.3
              valent Patie




                                10                                                                          8.9
                                                                                              8.4                 8.3           8.1
                                                                                                                        8.0           7.9
                                 8
                                                        6.2
                                        5.6                      5.6         5.6
   cent of Prev




                                 6              5.2
                                                52                     5.1
                                                                       51          5.2
                                                                                   52

                                 4

                                 2
Perc




                                 0
                                                      Utilizing Catheter                                   Utilizing Catheter
                                                           < 90 Days                                            > 90 Days
Percent of Prevalent Patients
                         with AV Graft - CPM
                                                                                    31%
                     35
                                                                                                  31
                                                                22%                          30
                     30
                                                                                        26
                     25                                                   23 23 23 23
           atients




                                                               22 22 22
                                                       20 21
                                                  19
                     20                   17 18
                                  16 16
                                   6 6
     % of Pa




                          14 15
                     15

                     10

                      5

                      0
                          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
                       with AV Graft - CPM
                  60    56
                                   52
                  50
                                          44
        atients




                  40
                                                  32     32     31
                  30
  % of Pa




                  20

                  10

                   0
                       2002       2003   2004    2005   2006   2007

                                         Network 14
The ESRD Network of Texas, Inc.
Percent of Prevalent Patients with
                 AVG and S
                       d Stenosis M i i
                                i Monitoring - CPM

                 120
                       99                               71%
                 100                                               69%
                            87 84
                                    80
 % of Patients




                  80                     72 72 72 71 71 71 71 69
                                                                 67 67 64
                                                                          62 62 61
                                                                                   58
                  60
      P




                  40

                  20

                   0
                       16 13 6      4    3   8 11   1 10 18 US 14 12 17   2   9   15 7   5

                                                      Network

The ESRD Network of Texas, Inc.
Percent of Prevalent Patients with
                 AVG and S
                       d Stenosis M i i
                                i Monitoring - CPM

                 100

                  90
                                  84
       atients




                  80   78
 % of Pa




                                                 72    72
                                         68                   69
                  70

                  60

                  50
                       2002       2003   2004   2005   2006   2007

The ESRD Network of Texas, Inc.
                                         Network 14
Fistula First Focus
Nephrologist awareness and early referral
p
patterns
Regional areas with system barriers
AVG conversion to Secondary AVF
  Focus on Assessing Failing AVG for conversion to
  Secondary AVF
  Pilot Project Ongoing- 6 Texas Facilities with
  historically high AVG rates (> 30% AVG x 3 years)
Nephrologist Profile Report:

                           Cath + AVF
                            or AVG                                                AVF
                                          AVF                Cath + AVF
                                                              or AVG
                          Physician                                       Texas         AVG
                           Physician                                      Texas

                          Catheter Only                             Catheter Only




           Physician            N                %         Texas            N              %
          AVF                   2               12.5    AVF                419            24.2
          AVG                   0                0.0    AVG                153             8.9
          Catheter ith
          C th t with                                   Catheter ith
                                                        C th t with
                                2               12.5                       431            24.9
          AVF or AVG                                    AVF or AVG
          Catheter Only        12               75.0    Catheter Only       726           42.0
              Total            16               100.0       Total          1729           100.0

                                    VA Used for First Chronic Dialysis Patients with > 12
                                    Months Nephrologist Pre-ESRD Care
                                                          Pre-

The ESRD Network of Texas, Inc.
AVF Prevalent AVF in Texas 03-08
                                                 03-
                                 Distributiion of Percent AVF Rate

                      140


                      120
          acilities




                      100
N ber of Fac




                      80


                      60
Num




                      40

                                                                                Sep '08
                      20                                                        Sep '07
                                                                                Sep '06
                                                                                Sep '05
                                                                                     05
                        0
                            10     20   30     40   50    60     70   80   90   Sep '04
                                                                                Oct '03
                                             Pe rcent AVF Rate
Other NW data &
   QI Projects
2004-
           2004-2007
Standardized Mortality Ratio (SMR)
Statistically Si ifi
St ti ti ll Significant SMR 2004-2007
                      t     2004-
           High                         Low
 28 Facilities               41 Facilities
 SMR range 1.22- 2.13
              1.22-          SMR range 0.00-0.74
                                          0.00-
 P value range 0.000-0.26
                 0.000-      P value range 0.00-0.049
                                             0.00-
 Patient Census 38-312
                  38-        Patient Census 29-372
                                              29-
 MRB follow up in progress
2004-
              2004-2008
 Patients on Incenter & Home Dialysis
             ents
Numbe of Patie
    er
 
                 




 Increasing Home Dialysis
Quality Improvement Project


 Benchmark facility results
Important practices in educating, referring, &
                                    referring,
      recruiting patients for home 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 educating, referring, &
                                      referring,
       recruiting patients for home dialysis
New staff receive education on home dialysis 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 utilized to determine suitability for home dialysis.
Change in facilities with Home
           Patients
           P ti t
Baseline 2006   After Project 2008
Improving
Management of
 Phosphorus
  Outcomes
Rationale and Goals
Phosphorus is important
  Mortality
  Quality of Life
  There is variability across facilities
Project Goals
  Increase percent of patients in target range
Distribution of Facilities By Percent of PD
    Patients with Serum Phosphorus 5.5 mg/dl or Lower
                                       55



                                      Opportunity
                 QOC Concern          to Improve            Benchmarks




Mean = 62.8
St Dev = 25.71
                           2007 Quality of Care Project (4th Quarter 2006 data)
Observational Data Have Shown Elevated Serum
Phosphorus Levels Are Associated With Increased Mortality

        Study          Data       Population           N              PO4       Increased
                                                                    (mg/dL)    Relative Risk
  Slinin Y t l
  Sli i Y, et al.    1993-
                     1993-1996       DMMS           14,829
                                                    14 829          5.4-6.3
                                                                    5.4
                                                                    5 4 -6 3       2%
                                                                    6.4-
                                                                    6.4-7.5        10%
                                                                     > 7.5         19%
  Melamed EW, et
          EW         1995-
                     1995-1998      CHOICE            593           5.1-6.0*
                                                                    5.1
                                                                    5 1-6 0*
                                                                      1-           8%
  al.                                                                > 6.0*        57%
  Block GA, et al.     1997          FMC            40,538          5.0-5.5
                                                                    5.0-           10%
                                   Database                         5.5-
                                                                    5.5-6.0        25%
  Young EW, et al.   1996-2001
                     1996-           DOPPS          17,236          Per 1          4%
                                                                    mg/dL
  Kalantar-
  Kalantar-Zadeh,    2001-2003
                     2001-          DaVita          58,058          > 6.0*     Increased†
                                                                               Increased†
  et al.                           Database
                          *Adjusted for vitamin D administration.
                          †Exact number not specified.
Continuing Opportunities for
          g pp
   Improvement in Texas

Barriers: Funding & NW Resources

Potential Projects:
P t ti l P j t
   K+ Baths / Protocols
   Abx/Cult Practices – Protocols?
   Catheter Management
Closing thoughts
Safety / Risks
   Staff Oversight / Vigilance
   DSHS Collaboration
   Medical Director Commitment
   M di l Di t C            it t
        “We Can Do Better”
“The medical direction of dialysis facilities
            has been … sometimes absent, feckless* or
                                   absent
            uninspired”

*lacking purpose
  without skill
  ineffective, incompetent
             ,      p
  lacking the courage to act in any meaningful way




                                                     Gutman, 2007
                                                     G t
                                    
                                                       

      CMS 2744 (2004-2006)
    Annual Facility Survey Data

                                         Regional
                                            g
               Fistula First           Collaborative &
                                                              Secondary
                                                              S    d
              Dashboard Data                                  AVF VAIP
                                       VA Workshops


         Quality of Care                 Quality of Care
                                       “Concern” Facilities
         Indicator Data

          CMS 2728 (2007)                           Access in Use at
    Medical Evidence Report Form                  Initiation of Dialysis
                                                                    y

                                    
                                                    
                                               Improving
     Clinical Performance
                                             Phosphorous
      Measures (CPM) Data
                                              Management
Recognitions
    g

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The State Of E In Sexas

  • 1. 2009 ESRD Network of Texas, Inc. Network Coordinating Council Meeting
  • 2. CHAIRMAN’S REPORT Richard Gibney, MD Gibney Network Elections Quality Improvement A Pause to Reflect Supporting Quality Care
  • 3. NOMINATING COMMITTEE 09-10 09- Melvin Laski, Lubbock Richard Gibney MD Waco Gibney, MD, Robert Hootkins, MD, Austin Cleve Collins, MD, San Antonio Tom Lowery MD Tyler Lowery, MD,
  • 4. Slate of Officers Melvin Laski, MD, Chairman Manny Alvarez, MD, Vice Chairman Larry McGowan, Treasurer Amy Hackney, Secretary Richard Gibney, MD Immediate Past Chairman Ruben Velez, MD MRB Chair Velez MD, Laura Yates, RN, At Large Charles Orji, MD, At Large Leigh Anne Tanzenburger, At Large 09- 09-10 EXECUTIVE COMMITTEE
  • 5. Network Coordinating Co ncil Net o k Coo dinating Council Election
  • 7. Q QUALITY IMPROVEMENT URGENCY TO CHANGE: Improve quality of care (↓harm) (↓harm). All / Patients & family benefit Win Staff (RN, PCT, SW, Dietitian, Physician ↓ Mortality, improve quality indicators. Evidence based medicine, best practices, more efficient time, , p , , patient flow. ↓Chance of liability. Our reputation (not national average or less). Transparency good! It i noble & uplifting to be the best at helping our fellow man. is bl lifti t b th b t t h l i f ll
  • 8. Q QUALITY IMPROVEMENT “The problem with life is, p , there is no SCARY music.” -- Robin Williams ↓Mortality, ↓Patients Harmed.
  • 9. Q QUALITY IMPROVEMENT DATA USE: Right things easy BIG GOALS! Bad things hard / Simple & visual. No denominator. N d i t “Hope is not a strategy.” “Complexity is the enemy of reliability.” Protocols, processes, Protocols processes systems flow (orders diagnosis (orders, diagnosis, & treatment.)
  • 10. WE HAVE BEEN CALLED TO A MINISTRY, WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON’S LIFE LIFE; A REAL AND TREASURED PRIVILEGE. -- James Reinertsen, M.D. September, 2008
  • 11. LOAVES AND FISHES This is not the age of information. This is not the age of information. Forget the news, g , and the radio, and the blurred screen. This is the time of loaves and fishes. People are hungry, and one good word is bread g for a thousand. --David Whyte
  • 12. Report from the Executive Director Glenda Harbert, RN, CNN, CPHQ
  • 13. MISSION Statement The ESRD Network of Texas, Inc. supports quality dialysis & kidney transplant healthcare th t l t h lth through patient h ti t services, education, quality q y improvement & data exchange. 2003
  • 14. Topics DSHS Referrals & Rules Network Growth Network Activities
  • 15. 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 DSHS C Council meeting on il ti 30 day comment period after the proposed rules are published l bli h d No decision yet if a public comment hearing will be held during the 30 day comment period
  • 16. DSHS responds to each comment submitted during the comment period – the comment is either accepted and the suggested change made, made or it is not and why After Aft comment period, fi l rule preamble t i d final l bl and final rules go to HHSC for final approval After approval, the final rules are published and become effective 30 days after publication www.dshs.tx.us/hfp/rules.shtm www dshs tx us/hfp/rules shtm
  • 18. Number of Cases & Levels
  • 19. Common Themes Unsafe Infection Control Practices Poor hand washing practices Inappropriate use of Personal Protective Equipment (PPE) Not disinfecting surfaces Failure to implement Quality Assessment and Performance Improvement (QAPI) Patient Safety Concerns Lack of patient assessments (pre, during & post) Disabling machine alarms
  • 20. Common Themes Vascular Access Outliers High Catheter Rate Low AVF Rate Unsafe Physical Environment Dirty floors Broken Tiles, etc. Water Treatment Practices Not testing properly Lack of staff knowledge Unsafe Reuse practices
  • 21. Communication Issues PCT’s not reporting critical treatment data/events to nurses: Failure to report Hyper & Hypo tension pre, during, and post dialysis treatments Initiating Sodium Profiling with ↑ BP Failure to: obtain accurate weights identify wet transducers communicate “Reportable Parameters” to physician or nurse
  • 22. Serious Situations Patient deaths attributed to nursing practice issues Phlebotomy of 1 liter of blood every treatment X 3 treatments Hep H B positive (+) conversion then converted ii ( ) i h d to negative (-) with pt. left in Isolation Room for extended period Initiating dialysis when water treatment out of parameters
  • 23. Serious Situations Use non-standard dialysate without appropriate monitoring pp p g Failure to recognize, report and track Adverse Events
  • 24. 2008 Network #14 Growth & Trends •CMS Certified Facilities • Facility Ownership • Growth in Patient Census • Patients Transplanted
  • 25. Network Growth Total Number of Texas Dialysis Facilities CMS Annual Facility Survey Data The ESRD Network of Texas, Inc.
  • 27. 2008 Texas Facility Ownership (%) 27
  • 28. Total Number of Texas Patients (Includes Home & In-Center HD and PD Patients) In-
  • 29. Total Transplants by Donor Type 29
  • 30. 2004- 2004-2007 Standardized Transplantation Ratio a da d d a p a a o a o (STR) UM KECC DFR report
  • 31. 2007 Percent Patients (<70 years old) on a ( 0 y a o d) o Transplant Waitlist UM KECC DFR report
  • 32. 2007 Percent Patients on the Waitlist by Subgroup Pe S aitlist ercent of Subgroup on the Wa
  • 33. Distribution of Percent of Texas Facility Patients on Waitlist 2007 UM KECC DFR report
  • 34. Paired donation Matches one incompatible donor/recipient pair to another pair with a complimentary incompatibility, incompatibility so that the donor of the first pair gives to p g the recipient of the second, and vice versa.
  • 35. Potential Donations 5000 anges 4000 Number of Possible Excha •100 donor - recipient pairs generates 4,950 potential paired exchanges 3000 2000 r 1000 0 1 11 21 31 41 51 61 71 81 91 101 Number of Pairs
  • 36. Alliance for Paired Donation Composed of 63 transplant centers in 22 states. 1st year APD facilitated 19 paired exchanges List of Texas Participating Centers (18) www.paireddonation.org
  • 37. Paired Donation Network Includes over 80 kidney transplant programs in i 23 states that are organized in five regional t t th t i d i fi i l consortia. 14 p i ed donor transplants have been done paired dono t n pl nt h e within the PDN system since October 08. Texas – 2 centers North Austin Medical Center Memorial Hermann Renal Transplant Center http://www.paireddonationnetwork.org/
  • 38. Activities of the Network Quality Improvement Outreach TEEC & Disaster preparedness Patient & Provider Technical Assistance & Education Involuntary Discharge Information Management
  • 39. Quality Improvement Lab data Collection Quality Improvement Projects Home Sweet Home Quality of Care Concerns & CPM’s CPM s Vascular Access Improvement Projects Severe Anemia 2 year outliers for clinical labs
  • 41. What is Wh t i TEEC? The mission of TEEC is to ensure a coordinated preparedness, plan, response and p recovery to emergency events affecting th T ff ti the Texas ESRD community.
  • 43. Important Lessons Learned Independent facilities must pre-plan for backup dialysis with another provider Patients should be encouraged to evacuate Any patient with limited mobility, support mobility systems and or transportation MUST be registered for evacuation with 211 Telling patients to go the hospital for dialysis is NOT a disaster plan!
  • 44. Involuntary Discharge 54 46 44 40 32 31 < 0.15% of total patients
  • 45. Monitoring & Profiling Complaints by Facility
  • 46. Percent of total Facilities with Complaints 1 Complaint 14.7%  2 Complaints 1.5%  3 Complaints 0.02%  3 Complaints 0 02%  None 83.78%  >3 Complaints 0.0% 
  • 47. Booklet Test Fall 2008 6 facilities- El Paso facilities- Paso, Angleton, Houston, Tyler, Lubbock Tyler Lubbock, McAllen 55 patients ti t In English and Spanish http://www.esrdnetwork.org/patients/education/resources.asp
  • 48. Test Method 9 volunteer RD’s were asked to participate – 6 completed the test RD’s were asked to select 9 patients (if possible) with the following characteristics to be representative of NW 14 patient g p p population – 43% Hispanic ethnicity n= 3 – 57% Non-Hispanic White= 4 including 1 other race, such as Asian if possible – 30.5% Black= 2 Of the 9 patients include at least 2 Non–readers 1 English speaking 1 Spanish speaking
  • 49. Ask Me Three Methodology* Selected readers were given the booklet to readd Non readers had the booklet read to them in either English or Spanish After the patient read the booklet (or had it p ( read to them) RD’s were asked to explain to patient : p * National Patient Safety Foundation
  • 50. Non Blaming, Non Shaming Blaming “We are testing how well we did We writing this booklet so patients can understand what it says. I would d t d h t ld like to ask you a few questions to see how well we did.” Not: Do you understand? Do D you hhave any questions? ti ?
  • 51. The RD then asked 3 simple questions and recorded the answers awarding 1 point for each correct answer accepting multiple answers A other category was i l d d for th t included f answers the RD deemed correct that were not one of th pre-selected t f the l t d answers
  • 52. Patient Scores Total score of > 4 considered booklet effective 50 of 55 > 4 (91%) Of the 5 that did not score at least 4 – 1 Hispanic white spanish speaking non- non- reader – 3 Non Hispanic white English reader* – 1 African American English reader reader* *Although it is not known, it is possible these patients were g , p p marginal readers. It is common for adult poor readers or non- non-readers to deny their literacy status.
  • 53. Average Score by Group Hispanic Hispanic Non Non Hispanic White Hispanic White Hispanic Hispanic Black A/A White ENG. White Spanish White White Black A/A ENG. non ENG. non Spanish non ENG. Spanish ENG. reader reader reader reader reader reader reader reader N=10 N=1 N=10 N=2 N=5 N=7 N=15 N=3 5.5 9 6.3 5 5.6 4.9 4.8 8.3
  • 54. Question #1: What is the main problem? Correct answer= thi t C t thirst
  • 55. What are things I can do about it? (strategies to control thirst) Percent responding Percent responding Other  approved by RD  Use smaller  as correct, 38% glass , 45% if Diabetic:  Control blood  sugar , 22% Use  Suck on  S k hard candy or  ice, 51% gum , 44% Don't  eat processed  eat processed meats , 25%
  • 56. Why is this important for me? Percent responding   Percent responding other , 9 less swelling, 35 not as thirsty, 29 less sob, 40 less fluid gain,  64 better for my  heart, 60
  • 57. Conclusions The booklet effectively educated patients of several demographics regarding: f ld hi di – The main topic- with 95% answering thirst correctly – Strategies to control thirst 22 51% 22-51% cited >1 of 5 answers determined in advance to be correct 38% cited another answer that the RD approved as correct Suck on ice was the strategy scoring the highest (51%)
  • 58. Conclusions, continued – Importance to them personally 29 64% 29-64% cited >1 of 5 answers determined in advance to be correct Less fluid gain was the reason scoring the g g highest (64%) Better for my heart second highest (60%) y g ( ) 9% cited another answer that the RD approved as correct
  • 59. Why do all that for a booklet y everyone likes & uses? Need to show effectiveness of outreach to CMS Learning new methods to address Health Literacy issues Demonstrating effectiveness
  • 60. Health Literacy: A Prescription to End Confusion. 90 million US adults: literacy skills below high school level Adults with limited literacy: less knowledge of disease management & health promoting behaviors i b h i report poorer health status less likely to use preventive services y p higher hospitalization rates & emergency service use less adherence >300 studies show health-related materials far exceed average reading ability of US adults Institute of Medicine, 2004 Medicine
  • 61. Health Literacy of American Adults National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Department of Education, 2003.
  • 62. Health Literacy “The degree to which individuals have the capacity to; p y ; obtain, process, and understand basic health information and services needed to make appropriate health decisions. decisions ” Healthy People 2010
  • 63. Improves Patient Safety A 2006 study examined patients’ abilities to understand five common instructions on prescription medications. Both patients with adequate and low literacy had difficulty understanding at least one of the five instructions.
  • 64. “What Did the Doctor Say?”* y Recommends making plain language a “universal precaution” in all patient encounters *Improving Health Literacy to Protect Patient Safety- Joint Commission
  • 65. What is plain language? • Plain language is communication that an audience can understand the first time they read or hear it. it What • The concept of using plain language is closely related to the concept of health literacy. Why y • Clear communication is critical to successful health care. care How
  • 66. Watch for more information on Health Literacy and Patient Education
  • 67. What happened to Crown Web? •Phase I- Pilot Project with 4 Networks & 8 Facilities F iliti •Phase II ? Spring or Summer 09 •Full Implementation ?? F ll I l t ti •For more Information- Special Session Saturday Aft S t d Afternoon
  • 68. Thank you for all that you do gharbert@nw14.esrd.net 469-916- 469-916-3801
  • 69. Report from Medical Review Board (MRB) Chairman Robert Hootkins MD, PhD, FACP, FASN R b t H tki MD PhD FACP
  • 70. My Assignment Today! y g y Review geographic representation and functions of MRB Share current NW #14 clinical indicator data Closing thoughts as outgoing “lame duck Chairman lame duck”
  • 71. MRB Functions Evaluate quality and appropriateness of care delivered to ESRD patients in Texas Propose Corrective Action Plans (CAP) for dialysis units with Level 2-3 deficiencies to Texas 2- Department of State Health Services (DSHS) Analyze NW #14 data and recommend clinical outcome profiling cut-points cut- Serve as primary advisory panel to Network to promote improved patient care and safety through QI activities Utilize NW #14 data to identify Network-wide y Network- improvement opportunities
  • 72. Current Geographic Representation of MRB Ruben Velez, MD Camille May, RN Ingemar Davidson, MD I D id Jennie Lang House, RD Trish White, RN Mary Beth Callahan, SW Dianne Morgan a e o ga James Cotton, MD Mohan Narayan, MD Stuart Goldstein ,MD Robert Hootkins, MD Donald Molony, MD Deborah Heinrich, RN Jane Louis, RD Jacqueline Lappin, MD J li L i Denise Hart, MD Mazeen Arar, MD Arar, Joyce Hernandez, SW y , Clyde Rutherford, MD Rutherford Anna Gonzalez Navid Saigal, MD Saigal, Kaylenne Duran, RN The ESRD Network of Texas, Inc.
  • 73. Information on Data & Projects ESRD Network of Texas, Inc.
  • 74. Comparative Clinical Indicator Data used by NW #14 Mandating Comparative Data Collection Sample Size Use Organization Data Level Network Clinical Random Identify and U.S. Performance CMS Sample NW QI (No Facility Measures (CPM) Patients Projects Specific Data) Quality of 100% of Facility, Identify Care(QOC) Network #14 eligible Network and outlier Indicator Project patients U.S. facilities Facility, Identify 100% of Fistula First CMS Network and VA outlier patients U.S. facilities Data All facility Facility, posted on patients with Network and Annual Dialysis DFC and CMS URR and ESA U.S. Facility Report used by Medicare State Billing Claims SMR, SHR, STR Surveyors
  • 76. Percent of Patients with URR > 65% - CPM 94 90% 89% 92 90 90 90 90 90 90 90 90 89 89 89 89 89 89 % of Patients 88 88 88 88 87 86 85 P 84 83 82 80 78 76 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.
  • 77. Percent of Patients with Kt/V > 1.2 - CPM 93% 94 91% 93 93 93 93 93 93 93 92 92 92 92 92 92 91 91 91 91 % of Patients 90 90 90 90 89 89 P 88 87 87 86 85 84 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.
  • 78. MRB Quality of Care Cut-Point for HD Adequacy (2007 data) More than 80% of facility patients have a URR of > 65% 95% of TX HD facilities (N= 391) met or exceeded th MRB quality cut-point! d d the lit cut- i t! t What about the 5% of TX facilities (N=19) that didn’t did ’ meet the cut point? h i 14 facilities 71- 71-80% of patients had a URR > 65% 3 facilities 61- 61-70% of patients had a URR > 65% 1 facility 51- 51-60% of patients had a URR > 65% 1 facility 0-10% of patients had a URR > 65%
  • 80. Percent of Patients with HGB < 10.0 - CPM 9 8 8 5% 5% 7 7 7 7 6 6 6 % of Patients 6 5 5 5 5 5 5 5 5 5 4 4 4 P 4 3 3 2 1 0 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.
  • 81. Percent of Patients with HGB > 11.0 - CPM 86% 88 86 82% 86 85 84 84 84 83 83 83 % of Patients 82 82 82 82 82 81 81 81 80 80 80 80 80 P 78 77 76 74 72 14 1 17 18 3 7 15 11 US 16 12 5 6 10 4 8 9 13 2 Network The ESRD Network of Texas, Inc.
  • 82. Percent of Patients with HGB 11.0-12.0 - CPM 11.0- 44% 50 39% 45 44 45 42 42 42 42 41 41 40 39 39 40 38 37 37 37 36 36 % of Patients 35 33 32 30 25 P 20 15 10 5 0 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.
  • 83. MRB Quality of Care Cut Point Cut-Point for HD Severe Anemia Management (2007 data) Less than 11% of facility patients have a Hemoglobin < 10.0 94% of TX HD facilities (N=413) met or exceeded the MRB quality cut-point! cut- What about the 6% of TX facilities (N=26) that didn’t meet the cut point for this Hgb range? 23 facilities 11- 11-20 % of patients with Hemoglobin < 10.0 1 facility 21-30% 21-30% of patients with Hemoglobin < 10.0 1 facility 41-50% of patients with Hemoglobin < 10.00 41- 1 facility 91-100% 91-100% of patients with Hemoglobin < 10.0 10 0
  • 84. MRB Quality of Care Cut-Point for HD Anemia Management (2007 data) More than 70% of facility patients have a Hemoglobin between > 10 0 and < 13 0 gm/dl H l bi b 10.0 d 13.0 /dl 90% of TX HD facilities (N 370) met or exceeded (N= the MRB quality cut-point! cut- What about the 10% of TX facilities (N=43) that didn’t meet the cut point for this Hgb range? 30 facilities 60.1- 60.1-70% of patients > 10.0 and < 13.0 gm/dl 8 facilities 50.1 50.1-60% of patients > 10.0 and < 13.0 gm/dl 4 facility 40.1- 40.1-50% of patients > 10.0 and < 13.0 gm/dl 1 facility 0-10% of patients > 10.0 and < 13.0 gm/dl
  • 86. Percent of Patients with Phosphorus 3.5-5.5 - CPM 3.5- 58% 70 52% 60 57 58 54 55 55 56 51 51 52 52 52 53 53 54 50 51 48 49 50 % of Patients 45 40 P 30 20 10 0 6 7 16 6 5 8 13 17 3 9 11 US 3 15 10 12 5 0 1 18 2 8 4 14 Network The ESRD Network of Texas, Inc.
  • 88. Percent of PD Patients with Kt/V ≥ 1.7 - QOC 2006 2007 100 95 91.1 89.9 90 85 ents 80 75 % of Patie 70 65 60 55 50 45 40 The ESRD Network of Texas, Inc.
  • 89. MRB Quality of Care Cut-Point for PD Adequacy (2007 data) More than 80% of facility patients have a Kt/V > 1.7 75% of TX PD facilities (N= 84) met or exceeded the MRB quality cut-point! th lit cut- i t! t What about the 25% of TX facilities (N=28) that didn’t did ’ meet the cut point? h i 18 facilities 71- 71-80% of patients met Kt/V > 1.7 2 facilities 61- 61-70% of patients met Kt/V > 1 7 1.7 1 facility 51- 51-60% of patients met Kt/V > 1.7 7 facilities 0-50% of patients met Kt/V > 1.7
  • 91. Percent of PD Patients with HGB < 10 0 - QOC 10.0 The ESRD Network of Texas, Inc.
  • 92. Percent of PD Patients with HGB ≥ 11 0 - QOC ith 11.0 90 2000 2001 2002 2003 85 2004 2005 2006 2007 81.9 80.4 80 79.1 78.3 tients 77.1 % of Pat 75 73.8 73 8 69.2 70 65 60 The ESRD Network of Texas, Inc.
  • 93. Percent of PD Patients with TSAT ≥ 20% - QOC ith The ESRD Network of Texas, Inc.
  • 94. MRB Quality of Care Cut Point Cut-Point for PD Severe Anemia Management (2007 data) Less than 11% of facility patients have a Hemoglobin < 10.0 77% of TX PD f iliti (N=77) met or exceeded the f facilities (N 77) t d d th MRB quality cut-point! cut- What b t th Wh t about the 23% of TX facilities (N=26) that f f iliti (N 26) th t didn’t meet the cut point for this Hgb range? 14 facilities 11- 11-20 % of patients with Hemoglobin < 10.0 6 facilities 21-30% 21-30% of patients with Hemoglobin < 10.0 6 facilities 41- 41-50% of patients with Hemoglobin < 10.0
  • 95. MRB Quality of Care Cut-Point for PD Anemia Management (2007 data) More than 70% of facility patients have a Hemoglobin between > 10 0 and < 13 0 gm/dl H l bi b 10.0 d 13.0 /dl 66% of TX PD facilities (N=77) met or exceeded the MRB quality cut-point! cut- What about the 34% of TX facilities (N=40) that didn’t meet the cut point for this Hgb range? 19 facilities 60.1- 60.1-70% of patients > 10.0 and < 13.0 gm/dl 6 facilities 50.1 50.1-60% of patients > 10.0 and < 13.0 gm/dl 9 facilities 40.1- 40.1-50% of patients > 10.0 and < 13.0 gm/dl 6 facilities 0-40% of patients > 10 0 and < 13 0 gm/dl 10.0 13.0
  • 97. Percent of PD Patients with ALB ≥ 4 0/3 7 - QOC ith 4.0/3.7 36 2000 2001 2002 2003 32 2004 2005 2006 2007 27.4 28 24.8 24 8 23.0 atients 24 21.3 20.3 20.6 20 % of Pa 16 12 8 4 0 The ESRD Network of Texas, Inc.
  • 99. AVF Utilization in the U.S. November 2008 70 64 51.4% 50.5% 60 57 57 56 55 55 52 51 51 51 51 50 50 50 49 48 48 47 50 47 Percent AVF 40 30 20 10 0 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.
  • 100. Improvement Needed to Meet 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 prevalent AVFs Assuming Equal Growth each Month 52.8% Where we need to be Where we are/were 52.0% 52.0% 51.8% 51.5% 50.9% 51.2% 51.2% 50.6% 50.3% AVF Rate R 50.4% 50.0% 49.7% 50.5% 50.4% 49.6% 49.4% 49.9% 49.1% 49.6% 49.8% 9 6% 50.0% 48.8% 48.8% 48.5% 48.8% 48.5% 48.6% 48.0% Mar-08 Apr-08 May-08 Jun-08 M 08 A 08 M 08 J 08 Jul-08 Aug-08 S J l 08 A 08 Sep-08 O t 08 N 08 D 08 J 08 Oct-08 Nov-08 Dec-08 Jan-09 F b 09 M 09 09 Feb-09 Mar-09 Month
  • 101. Percent of Prevalent Patients with Catheter (with/without AVF or AVG, regardless of duration of use) - CPM use) 40 27% 34 35 31 31 31 32 32 32 21% 30 27 27 27 28 28 28 % of Patients 24 24 25 25 23 21 21 20 P 15 10 5 0 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.
  • 102. Percent of Prevalent Patients with Catheter - CPM 30 25 24 23 21 21 % of Patients 20 19 17 15 10 5 0 2002 2003 2004 2005 2006 2007 Network 14 The ESRD Network of Texas, Inc.
  • 103. September 2008 Chart 2: Prevalent Texas Patients With Catheter Only Oct 2003 Oct 2004 Sep 2005 Sep 2006 Sep 2007 Mar 2008 Sep 2008 12 ents 9.3 valent Patie 10 8.9 8.4 8.3 8.1 8.0 7.9 8 6.2 5.6 5.6 5.6 cent of Prev 6 5.2 52 5.1 51 5.2 52 4 2 Perc 0 Utilizing Catheter Utilizing Catheter < 90 Days > 90 Days
  • 104. Percent of Prevalent Patients with AV Graft - CPM 31% 35 31 22% 30 30 26 25 23 23 23 23 atients 22 22 22 20 21 19 20 17 18 16 16 6 6 % of Pa 14 15 15 10 5 0 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.
  • 105. Percent of Prevalent Patients with AV Graft - CPM 60 56 52 50 44 atients 40 32 32 31 30 % of Pa 20 10 0 2002 2003 2004 2005 2006 2007 Network 14 The ESRD Network of Texas, Inc.
  • 106. Percent of Prevalent Patients with AVG and S d Stenosis M i i i Monitoring - CPM 120 99 71% 100 69% 87 84 80 % of Patients 80 72 72 72 71 71 71 71 69 67 67 64 62 62 61 58 60 P 40 20 0 16 13 6 4 3 8 11 1 10 18 US 14 12 17 2 9 15 7 5 Network The ESRD Network of Texas, Inc.
  • 107. Percent of Prevalent Patients with AVG and S d Stenosis M i i i Monitoring - CPM 100 90 84 atients 80 78 % of Pa 72 72 68 69 70 60 50 2002 2003 2004 2005 2006 2007 The ESRD Network of Texas, Inc. Network 14
  • 108. Fistula First Focus Nephrologist awareness and early referral p patterns Regional areas with system barriers AVG conversion to Secondary AVF Focus on Assessing Failing AVG for conversion to Secondary AVF Pilot Project Ongoing- 6 Texas Facilities with historically high AVG rates (> 30% AVG x 3 years)
  • 109. Nephrologist Profile Report: Cath + AVF or AVG AVF AVF Cath + AVF or AVG Physician Texas AVG Physician Texas Catheter Only Catheter Only Physician N % Texas N % AVF 2 12.5 AVF 419 24.2 AVG 0 0.0 AVG 153 8.9 Catheter ith C th t with Catheter ith C th t with 2 12.5 431 24.9 AVF or AVG AVF or AVG Catheter Only 12 75.0 Catheter Only 726 42.0 Total 16 100.0 Total 1729 100.0 VA Used for First Chronic Dialysis Patients with > 12 Months Nephrologist Pre-ESRD Care Pre- The ESRD Network of Texas, Inc.
  • 110. AVF Prevalent AVF in Texas 03-08 03- Distributiion of Percent AVF Rate 140 120 acilities 100 N ber of Fac 80 60 Num 40 Sep '08 20 Sep '07 Sep '06 Sep '05 05 0 10 20 30 40 50 60 70 80 90 Sep '04 Oct '03 Pe rcent AVF Rate
  • 111. Other NW data & QI Projects
  • 112. 2004- 2004-2007 Standardized Mortality Ratio (SMR)
  • 113. Statistically Si ifi St ti ti ll Significant SMR 2004-2007 t 2004- High Low 28 Facilities 41 Facilities SMR range 1.22- 2.13 1.22- SMR range 0.00-0.74 0.00- P value range 0.000-0.26 0.000- P value range 0.00-0.049 0.00- Patient Census 38-312 38- Patient Census 29-372 29- MRB follow up in progress
  • 114. 2004- 2004-2008 Patients on Incenter & Home Dialysis ents Numbe of Patie er
  • 115.     Increasing Home Dialysis Quality Improvement Project Benchmark facility results
  • 116. Important practices in educating, referring, & referring, recruiting patients for home 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.
  • 117. Important practices in educating, referring, & referring, recruiting patients for home dialysis New staff receive education on home dialysis 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 utilized to determine suitability for home dialysis.
  • 118. Change in facilities with Home Patients P ti t Baseline 2006 After Project 2008
  • 120. Rationale and Goals Phosphorus is important Mortality Quality of Life There is variability across facilities Project Goals Increase percent of patients in target range
  • 121. Distribution of Facilities By Percent of PD Patients with Serum Phosphorus 5.5 mg/dl or Lower 55 Opportunity QOC Concern to Improve Benchmarks Mean = 62.8 St Dev = 25.71 2007 Quality of Care Project (4th Quarter 2006 data)
  • 122. Observational Data Have Shown Elevated Serum Phosphorus Levels Are Associated With Increased Mortality Study Data Population N PO4 Increased (mg/dL) Relative Risk Slinin Y t l Sli i Y, et al. 1993- 1993-1996 DMMS 14,829 14 829 5.4-6.3 5.4 5 4 -6 3 2% 6.4- 6.4-7.5 10% > 7.5 19% Melamed EW, et EW 1995- 1995-1998 CHOICE 593 5.1-6.0* 5.1 5 1-6 0* 1- 8% al. > 6.0* 57% Block GA, et al. 1997 FMC 40,538 5.0-5.5 5.0- 10% Database 5.5- 5.5-6.0 25% Young EW, et al. 1996-2001 1996- DOPPS 17,236 Per 1 4% mg/dL Kalantar- Kalantar-Zadeh, 2001-2003 2001- DaVita 58,058 > 6.0* Increased† Increased† et al. Database *Adjusted for vitamin D administration. †Exact number not specified.
  • 123. Continuing Opportunities for g pp Improvement in Texas Barriers: Funding & NW Resources Potential Projects: P t ti l P j t K+ Baths / Protocols Abx/Cult Practices – Protocols? Catheter Management
  • 124. Closing thoughts Safety / Risks Staff Oversight / Vigilance DSHS Collaboration Medical Director Commitment M di l Di t C it t “We Can Do Better”
  • 125. “The medical direction of dialysis facilities has been … sometimes absent, feckless* or absent uninspired” *lacking purpose without skill ineffective, incompetent , p lacking the courage to act in any meaningful way Gutman, 2007 G t
  • 126.         CMS 2744 (2004-2006) Annual Facility Survey Data Regional g Fistula First Collaborative & Secondary S d Dashboard Data AVF VAIP VA Workshops Quality of Care Quality of Care “Concern” Facilities Indicator Data CMS 2728 (2007) Access in Use at Medical Evidence Report Form Initiation of Dialysis y         Improving Clinical Performance Phosphorous Measures (CPM) Data Management