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Clinical Indicator Goals Project Shean Strong, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 December 14, 2009 Slide 2 Clinical Indicator Goals Project Background: Clinical Performance Measures (CPM) Project: Started in 1994 Random sampling of HD and PD patients Collection of lab values October December (HD facilities) October March (PD facilities) Slide 3 Clinical Indicator Goals Project Laboratory values collected: Hemoglobin TSAT Ferritin URR Kt/V Albumin Calcium Phosphorus Slide 4 Clinical Indicator Goals Project Uses of data: Provides comparative data for facilities National and local benchmarks Allows the Network to identify areas for improvement within patient care Allows the Network to assess the standard practice of the community for specific clinical indicators The basis for setting Network goals Slide 5 Clinical Indicator Goals Project Lab Data Collection (Elab) Project: Started in 1998 Nearly 100% sampling of HD and PD patients Collection of lab values for the last quarter of each year Same lab values collected as CPM project Slide 6 Clinical Indicator Goals Project Uses of data: Facility-specific generated reports Provides comparative data for facilities National and Network Allow facilities to identify area(s) for improvement within patient care Allows the Network to identify facilities who need to improve outcomes in specific clinical indicators Slide 7 Clinical Indicator Goals Project Clinical Performance Goals - Network goals: Goals are based on past performance, CMS thresholds and the NKF/KDOQI Clinical Practice Guidelines. Provides a measurement tool to assess facility patient care processes and outcomes and identify opportunities for improvement. Slide 8 Clinical Indicator Goals Project Expectation is that facilities not meeting expected performance standards be monitored by the Network and develop internal quality monitors to promote continuous improvement. Slide 9 Clinical Indicator Goals Project 2009-2010 Clinical Performance Goals: CPM C LINICAL I NDICATOR Network 18 (2008 CPM) U.S. (2008 CPM) Network 18 (2009 LDC) Network Goals for 2009-2010 (% of Patients) A NEMIA M ANAGEMENT % of Patients with mean Hgb > 11.0 g/dL. 8482 % of Patients with mean Hgb < 10 g/dL. 454.6< 4% % of Patients with mean Hgb 10-12g/dL. (CMS 2008 CPMs adopted effective 04/01/08.) 51505552% % of Patients with mean Hgb > 12 g/dL (As reported on the Dialysis Facility Report). 45 40.4 Slide 10 Clinical Indicator Goals Project CPM C LINICAL I NDICATOR Network 18 (2008 CPM) U.S. (2008 CPM) Network 18 (2009 LDC) Network Goals for 2009-2010 (% of Patients) A DEQUACY OF D IALYSIS % of Patients with mean URR > 65%. 888987.689% % of Patients with mean single session spKt/V > 1.2. 92919492% % of patients with mean weekly Kt/V urea > 1.7. 8488.9CMS = 80% Slide 11 Clinical Indicator Goals Project CPM C LINICAL I NDICATOR Network 18 (2008 CPM) U.S. (2008 CPM) Network 18 (2009 LDC) Network Goals for 2009-2010 (% of Patients) N UTRITIONAL S TATUS % of HD Patients with mean Serum Albumin > 3.5/3.2 g/dL (BCG/BCP) 85 82 84.485% % of HD Patients with mean Serum Albumin > 4.0/3.7 g/dL (BCG/BCP) 42 34 40.2 % of PD patients with mean Serum Albumin > 3.5/3.2 g/dL (BCG/BCP). 6269.865%** ** The goal was set by the MRB because PD patients lose albumin with the PD fluid. Slide 12 Clinical Indicator Goals Project CPM C LINICAL I NDICATOR Network 18 (2008 CPM) U.S. (2008 CPM) Network 18 (2009 LDC) Network Goals for 2009-2010 (% of Patients) V ASCULAR A CCESS % of Prevalent Patients with AVF 55 49 55.8% (Fistula First SIMS report March 2009) CMS = 66% NW goal = 57.8% Stretch Goal = 58.0% % of Prevalent Patients with AVG 23 22 20.6% (Fistula First SIMS report March 2009) CMS/NW = < 24% % of Prevalent Patients with Catheter > 90 days 1721 8.2% (Fistula First SIMS report March 2009) CMS/NW = < 10% Slide 13 Clinical Indicator Goals Project Quality Improvement Work Plan: (QIWP) Requirement under the Networks contract Consists of 4 specific areas: Vascular Access - Fistula First Clinical Performance Measures Network-specific quality improvement Facility-specific quality improvement Slide 14 Clinical Indicator Goals Project Clinical Indicator Goals Project: Inclusion Criteria: Facilities not meeting Network goals for anemia (4% of patients with Hgb < 10) Patient census of > 50 patients (HD) Patient census of > 20 patients (PD) Exclusion Criteria: Acute/transitional facilities Patient census < 50 patients (HD) Patient census < 20 patients (PD) VHA facilities Facilities participating in CROWNWeb Phase 2 Slide 15 Clinical Indicator Goals Project Objective: All facilities will be required to develop a QAPI (Quality Assessment and Performance Improvement) Plan utilizing the PDSA model to improve their sub-10 Hgb, implement those plans and monitor their progress. Goal: Decrease the percentage of patients with a Hgb < 10 by at least 2 percentage points by April 2010. Timeline: October 2009 April 2010 Slide 16 Clinical Indicator Goals Project Due dates: Run Charts (JuneAugust 2009): due September 30, 2009: QAPI: due January 15, 2010 Quarterly Run Charts: Oct-Dec 2009 (to be distributed in January) Jan-Mar 2010 (to be distributed in April) Slide 17 Clinical Indicator Goals Project Network Responsibilities: Project Leader Instruct/assist with the QI process Distribute templates for RCA and PDSA Distribute resources and evaluate their usefulness Provide technical assistance as necessary Conduct facility site visits as necessary Slide 18 Clinical Indicator Goals Project Facility Responsibility: Conduct a root-cause analysis and develop a QAPI Plan Submit a copy of the QAPI plan to the Network Implement QAPI plan and revise as necessary during the project Monitor facilitys progress towards achieving the goal Follow project timelines/due dates Submit requested documents for the project in a timely manner Slide 19 Quality Assessment and Performance Improvement Plan (QAPI) 494.110: (V626) Condition The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. Slide 20 Quality Assessment and Performance Improvement Plan (QAPI) Interdisciplinary Team: (minimum) o Physician o Registered nurse o Social Worker o Dietitian Slide 21 Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Program Scope: 1. The program must include, but not limited to, an ongoing program that achieves measurable improvement in healthcare outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. Slide 22 Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Program Scope: 2. The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. Slide 23 Quality Assessment and Performance Improvement Plan (QAPI) (continued) Standard: Monitoring performance improvement: The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. Slide 24 Quality Improvement Process The process involves: Defining the problem Investigating through gathering evidence Identifying root causes Implementing solutions Monitoring those solutions to ensure they continue to prevent the original problem. Rootcauseanalybasics.com Slide 25 Quality Improvement Process (continued) Root Cause Analysis (RCA): At its most basic, the process asks three questions, which together provide the framework of a root cause analysis investigation: 1. What was the problem? 2. What were the causes of the problem? 3. What actions should be taken to prevent the problem from occurring again? Rootcauseanalybasics.com Slide 26 Quality Improvement Process (continued) Root cause analysis can use a variety of techniques to uncover root causes, including cause mapping, change analysis, the Ishikawa fishbone diagram, 5 Whys, and others. All are designed to analyze the elements affecting a particular outcome to determine the root causes. Rootcauseanalybasics.com Slide 27 Quality Improvement Process (continued) Root Cause Analysis Investigations: Every cause uncovered by RCA must be backed up by evidence. RCA usually uncovers a system of root causes. RCA uncovers specific causes and effects. RCA results in executable, quantifiable solutions that may be monitored. Rootcauseanalybasics.com Slide 28 Quality Improvement Process (continued) Root Cause Analysis Investigations: (continued) RCA does not point blame at any one person or group, but simply identifies a system of causes and effects that lead to and incident. RCA focuses on past events. Rootcauseanalybasics.com Slide 29 Quality Improvement Process (continued) Fishbone Diagram (aka: Cause and Effect Diagram) The fishbone diagram will help to visually display the many potential causes for a specific problem or effect. Slide 30 Quality Improvement Process (continued) Fishbone Diagram (continued) The Cause-and-Effect diagram can be used by individuals or teams - most effective by a group. The team assists by making suggestions of possible causes until no more causes can be suggested. Once the entire fishbone is complete, a team discussion takes place to decide what are the most likely root causes of the problem. Slide 31 Quality Improvement Process (continued) Fishbone Diagram: (continued) Benefits of a fishbone diagram: It helps teams understand that there are many causes that contribute to an effect. It graphically displays the relationship of the causes to the effect and to each other. It helps to identify areas for improvement. Institute for Healthcare Improvement Slide 32 Slide 33 Quality Improvement Process (continued) 5 Whys: Repeatedly asking the question Why to peel away the layers of symptoms which can lead to the root cause of a problem. Although this technique is called "5 Whys," you may find that you will need to ask the question fewer or more times than five before you find the issue related to a problem. Six Sigma (www.isixsigma.com) Slide 34 Quality Improvement Process (continued) Benefits Of The 5 Whys Help identify root cause of a problem. Determine the relationship between different root causes of a problem. One of the simplest tools; easy to complete without statistical analysis. Six Sigma (www.isixsigma.com) Slide 35 Quality Improvement Process (continued) Whys And The Fishbone Diagram The 5 Whys can be used individually or as a part of the fishbone diagram. The fishbone diagram helps you explore all potential or real causes that result in a single defect or failure. Once all inputs are established on the fishbone, you can use the 5 Whys technique to drill down to the root causes. Six Sigma (www.isixsigma.com) Slide 36 Whys And The Fishbone Diagram Six Sigma (www.isixsigma.com) Slide 37 Quality Improvement Process: (continued) Plan-Do-Study-Act: PDSA is the format the Network uses for developing a QAPI plan. ACTPLAN STUDY DO Slide 38 Quality Improvement Process: (continued) Quality improvement is a continuous cycle of planning, implementing strategies, evaluating the effectiveness of these strategies and reflection to see what further improvements can be made. Royal Childrens Hospital Melbourne Clinical Quality & Safety Slide 39 Quality Improvement Process: (continued) PDSA approaches promote action by getting clinicians to reflect and brainstorm strategies that they hope will lead to improvement. It also promotes evaluation of these changes once the strategies have been implemented. Royal Childrens Hospital Melbourne Clinical Quality & Safety Slide 40 Quality Improvement Process: (continued) PDSA is a cycle of improvement that involves asking three key questions: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in an improvement? NHS Scotland (www.clinicalgovernance.scot.nhs.uk Slide 41 Adopted from IHI Website, June 2007 PROJECT: TEAM: (List all members) BACKGROUND: (Summary of facilitys identified problem and description of what the facility has been doing to improve the problem.) Step 1. PLAN: Plan the test. What is the objective of this improvement cycle? What is the goal? (Include a numeric goal to achieve.) Develop a plan to achieve the goal? (List steps of the plan this will allow you to identify the step that may need modifying/revising if necessary.) 2 of 3 pages What data sources are needed for the test? (What data sources will you be using to monitor your progress?) What measures are used to analyze if you are achieving the goal? B ASELINE : Measure: (Numerical formula) Monitoring frequency : PDSA Template Slide 42 Step 2. DO: Try out the test on a small scale. Implement the plan. Document problems and unexpected observations. Step 3. STUDY: Set aside time to analyze the data and study the results. Analyze the results and compare the results with your goal. Step 4. ACT: Determine if the test was successful or the plan needs to be revised. If the test was successful, how will you implement the plan on a wider scale? If it was not successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes? Slide 43 Quality Improvement Process: (continued) Plan: Set your objective for the project Set goals to achieve (numerical goals and a target date) Develop your plan on how you will improve your identified problem Include a plan for collecting data List data sources you will use to monitor your progress for the project Slide 44 Quality Improvement Process: (continued) Plan (continued): Write out the measure you will be using to analyze if you are achieving your goal. (numerical formula) Example: # of prevalent patients using AVF as primary access = AVF rate Total # of patients at the facility Slide 45 Quality Improvement Process: (continued) Plan (continued): Note the frequency in which you will conduct measurement of your progress Note your baseline for comparison towards your goal Slide 46 Quality Improvement Process: (continued) Do: Implement your plan Document problems and unexpected observations of your plan Study: Analyze the results and compare it to the goal This analysis should be conducted with the interdisciplinary team. Slide 47 Quality Improvement Process: (continued) Act: Is your plan successful? How will you ensure continued improvement? If it wasnt successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes? Slide 48 Plan-Do-Study-Act (PDSA) (continued ) The PDSA cycle is a continuous cycle. It allows you to frequently assess your plan and make revisions as necessary to achieve your goal. Your plan should be reviewed at least monthly and/or when you realize that your strategy or activity is not working. Slide 49 Quality Improvement Process: (continued) Note your progress on your form so that you have a record of the strategies/activities youve attempted and results of those attempts as well as the revisions you have made to improve your plan. Slide 50 Conditions for Coverage: Anemia Management The ESRD Conditions for Coverage include anemia as one of the clinical indicators required to be addressed in both the patient assessment and the facilitys QAPI program. FMQAI Network 7 Slide 51 Conditions for Coverage: Anemia Management V405: Evaluation of factors associated with anemia, such as hematocrit, hemoglobin, iron stores, and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent(s). V632: Anemia management. Slide 52 Inadequate EPO dose Iron deficiency (True or Functional) Blood loss Infection or inflammation Aluminum toxicity Factors that contribute to anemia or lead to ESA hypo-responsiveness: FMQAI-Network 7 Slide 53 Factors that contribute to anemia or lead to ESA hypo-responsiveness: (continued) Secondary Hyperparathyroidism Co-existing medical conditions Hemolysis Malnutrition Vitamin deficiency (B12, Folic Acid, B6) FMQAI-Network 7 Slide 54 Factors that contribute to anemia or lead to ESA hypo-responsiveness: (continued) Evaluation for hypo-response is indicated when patient response to EPO administration is not observed. Once identified the underlying cause can be addressed When the cause is resolved, ESA dose can be adjusted to prevent from exceeding recommended range. FMQAI-Network 7 Slide 55 Document from Amgen Slide 56 Anemia Management: Lab Values Laboratory Monitoring for Anemia: Hemoglobin and Hematocrit Transferrin Saturation (Tsat) Ferritin Reticulocyte hemoglobin content (CHr) Slide 57 Summary: Facility to conduct a root-cause analysis of why your patients have a Hgb of < 10. Develop a Quality Assessment Performance Improvement (QAPI) Plan to decrease the percentage of patients with a sub-10 hemoglobin. QAPI must be signed by the Medical Director Submit a copy to the Network by January 15, 2010. ONLY STEP 1 (PLAN) is due on January 15 th. Slide 58 Summary: Implement and monitor progress of your QAPI plan. The Network will distribute quarterly run charts to monitor progress. Slide 59 Project Communication: To communicate more efficiently with you about this project and to be more eco- friendly, we are creating a listserv of all the facilities in this project. In the past, we have had e-mail delivery problems with facility firewalls, please ensure you are able to receive e-mails from us about the project. Consult with your IT Department to assist you. Slide 60 Shean Strong, MBA, QI Director sstrong@nw18.esrd.net Lisle Mukai, RN, QI Coordinator lmukai@nw18.esrd.net ESRD Network 18 323-962-2020 Network 18 website: www.esrdnetwork18.orgwww.esrdnetwork18.org