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
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
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
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
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!
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.
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
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
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
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