end -stage renal disease network of the ohio river … · calcium levels, specifically...
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AIM 3: ESRD Quality Incentive Program (QIP) Quality Improvement Activity
C.4.3.A Support the ESRD QIP, Dialysis Facility Compare, Star Ratings, and Dialysis Reports for
Performance and Assessment
ESRD Network # Network 9
ESRD Network
Name
IPRO ESRD Network of the Ohio River Valley
Contract
Number
Contract # HHSM-500-2016-00009C
Title of the QIA AIM 3: ESRD Quality Incentive Program (QIP) Quality Improvement Activity-
Hypercalcemia
Aim, Domain
and Sub
Domain
C.4.3.A Support the ESRD QIP, Dialysis Facility Compare, Star Ratings, and Dialysis
Reports for Performance and Assessment
QIA Contact
Person
Deborah DeWalt, MSN, RN – Quality Improvement Director
Susan Swan-Blohm, BS, OCDT- Quality Improvement Coordinator
Contracting
Officer’s
Representative
Commander Todd Johnson, MSW, LCSW
Dallas Division of Quality Improvement
Centers for Medicare and Medicaid Services
Current Date February 3rd, 2017
Submission
Date / Version
February 10th
, 2017, v1
II Objectives Topic
The End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) is a value-based-
purchasing program developed to promote high-quality services for the ESRD
community. This program is designed to alter payment based on the quality of care
received at outpatient dialysis facilities. Those facilities that do not meet or exceed
certain performance standards can receive up to a two percent payment reduction for all
services during the applicable payment year (CMS.gov, 2015).
The Centers for Medicare and Medicaid Services (CMS) publically reports facility ESRD
QIP scores on the Dialysis Facility Compare Website and requires that the facility display
their scores, using the Performance Score Certificate (PSC), in a prominent patient area.
This certificate displays the performance on each ESRD quality measure identified for
that year. One clinical quality indicator is the measure of mineral metabolism, including
calcium levels, specifically hypercalcemia. Hypercalcemia is a higher than normal level of
calcium in the blood, which can affect almost every body system, and is a common
comorbidity caused by renal failure. High levels of calcium in the blood can result in
muscle weakness, hypertension, constipation, anorexia, nausea, fatigue, and pain
(Skugor & Milas, 2009). For the 2017 project period, CMS has determined that one of
the primary QIP measures to be evaluated and improved upon would be hypercalcemia.
Network 9 has reviewed facilities in their region and has selected Hypercalcemia as the
project focus for the 2017 QIP QIA.
RCA Overview and Interventions
Individual facility root cause analyses (RCA) will be conducted during the month of
February to identify the likely causes of facility level hypercalcemia and loss of points on
the hypercalcemia QIP measure.
Project interventions will include, but are not limited to:
• Facility Level Root Cause Analysis
• Tailored PDSA Interventions based on RCA results
• Network support for implementation of interventions
Outcome Objectives
The goal of this project is to improve rates of hypercalcemia at the facility level, thereby
End-Stage Renal Disease Network of the Ohio River Valley Network 9 HHSM-500-2016-00009C
increasing scores for this measure on the ESRD Quality Incentive Program (QIP). In order
to meet CMS criteria for this project, facilities had to perform poorly on the
hypercalcemia measure for the 12-month baseline period from November 2015 to
October 2016 and show an ongoing facility trend of hypercalcemia.
Inclusion Criteria
Any outpatient ESRD facility that is ESRD QIP eligible and had a reduction in QIP points
during the 2017 payment year, as well as those showing a continued trend of
hypercalcemia at the facility level during the baseline period (November 2015- October
2016).
Exclusion Criteria
Network 9 excluded the following facilities from this QIA :
• Any facility with less than 25 eligible patients
• Any facility that is not ESRD QIP eligible
• Pediatric facilities
• Hospital based facilities
• Home dialysis programs
Rationale for these exclusions include a lack of available data for the QIP to determine
facility eligibility as defined in the CMS Statement of Work (SOW).
Time-Period
This project will be based on a baseline period of twelve months (November 2015 -
October 2016) and an intervention period that concludes by October of the contract
year. Goals for this project include a twenty- five percent (25%) relative improvement
from baseline in rates of hypercalcemia or the QIP threshold being exceeded for three
(3) months or more and a minimum of eight (8) facilities completing the PDSA cycle by
the evaluation period in September or October of the contract year.
Methods
Improvement for this project will be defined as facilities:
1. Achieving either a 25% relative improvement from baseline hypercalcemia rate
or,
2. Exceeding the QIP threshold for the measure for three (3) months or more
consecutively.
Training Materials
1. Facility notification letter including project expectations, and roles and
responsibilities for project intervention.
2. Root Cause Analysis (RCA) form to evaluate causes for high calcium levels in the
facility
3. PDSA forms and suggestions for improvement of calcium levels at the facility
4. Educational materials for staff and patients about mineral metabolism
management (calcium in particular) including a staff pneumonic to help
remember causes of high calcium (CHIMPANZEE) and for patients to be more
aware of symptoms of high calcium.
Project Plan
1. Identify facilities and notify of inclusion in project.
2. Distribute training materials to facilities and with timeline for the project
3. Conduct individual facility training sessions on RCA/ PDSA process
4. Analyze results monthly or as data is available to identify areas of success,
needed improvement, and barriers identified during discussions with
facilities.
5. Provide ongoing distribution of educational materials and analysis of results
from both facilities and patients to determine effectiveness of materials
shared.
6. Support facilities through use of PDSA cycle and interventions.
7. Participate in in CMS “Virtual Conferences” to share project successes,
barriers, and areas for improvement.
8. Provide a monthly update on facility progress toward goal assuring that
facilities who achieve the stated outcomes are graduated and replaced as
outlined in the statement of work.
Advisory Committee Activity
Members of the Network Council and Medical Review Board, as well as facility
representatives, and patients will participate in conference calls and face-to- face
meetings before rollout and intermittently throughout the project to evaluate progress
and provide feedback for the project. This feedback can be shared with the community
at large to assist in improving mineral metabolism management at the facility level.
Education/ Process Improvement
Summary of Proposed Intervention Strategies by Target Audience
Intervention Tools and Strategies Providers Patients
Staff education –individual discussions and materials •
Patient education - materials, brochures from known sources •
Technical assistance •
Advisory Committee • •
Calcium Management Tools to Assist Improvements • •
Identify barriers • •
Identify and share best practices • •
Perceived Barriers
• Patient compliance with medication regimen, diet, and medications cannot be
predicted or accounted for in this project.
• Limitations at the facility level to change protocols set by corporations.
• Co-morbidities that exist in the ESRD population which make improvement in
some patients challenging, would require individual patient monitoring and
implementation
• Data is not currently available as a CROWNWeb report to easily extract in a
timely manner and to monitor hypercalcemia progress in these facilities.
• Large Dialysis Organizations (LDO) have already begun working on this measure
in preparation for the ESRD QIP and thus may have impacted the rates of
hypercalcemia at the facility level prior to project initiation
Mitigation Strategies
• Provide patients with education about the importance of following diet and
medication recommendations, including how these impact health
• Discuss with corporations any facilities that may need exception criteria or
assistance with protocol development; work with independent facilities to
establish a clear protocol for mineral metabolism management to ensure
progress toward goal, and need for intervention.
• Help facilities identify individual patient challenges to work toward individual
patient education.
• Assist facilities with proper reporting in the CROWNWeb system to allow for
progress tracking and evaluation of effectiveness of education.
• Perform rapid cycle improvement to correct any deficiencies in identified in
processes.
• Work with LDO providers to identify any prior interventions for this measure
that would impact outcomes for this project and adjust as necessary.
Sustainability
Throughout this project, the Network will seek to identify common barriers and work
toward developing systems, education, and resources to overcome these challenges.
Possible resources include checklists for identification of mineral metabolism monitoring,
patient educational resource development, and guidance with development of care
plans that coordinate family assistance and care when needed. The use of these
resources across multiple groups will incorporate best practices and ideas that support
long-term sustenance of this project.
III Background Through use of the Quality Incentive Program (QIP) Scores from payment year 2016
(driven from 2014 data), the Network identified 31 facilities that lost five (5) points
or greater out of 10 possible points, for the hypercalcemia measure. These facilities
have lost points for the PY 2016 and will continue to lose points in the PY 2017 due to
high calcium rates among their patient populations. Clinic selection is based on the most
current calcium rates November 2015-October 2016. Following this review, the Network
has chosen 10 facilities to be part of the QIP QIA.
Opportunity for Improvement/Potential for Change
While evaluating the opportunity for improvement the Network found that 72 facilities
lost points for hypercalcemia in QIP, which is double the number we identified in the
program in our base year. This result supports an ongoing opportunity for improvement
in Network 9.
Each facility may have a different potential for change, and varied focus. In some cases,
the RCA may reveal that the problem is a patient based problem, while in others it may
be a physician/facility protocol level problem that must be addressed to improve.
Quality Indicators
Process Measures:
• Creating a change in facility protocols.
• Implementation of patient educational programming
• Improved facility reporting of calcium levels in CROWNWeb throughout the
project period
Outcome Measure:
• Reduce Hypercalcemia rate at the facility level by either a relative 25% (from
baseline) or to exceed the QIP threshold for a period of three consecutive
months.
Following the technical specifications of the hypercalcemia measure in the ESRD QIP, the
Network will be evaluating facilities based on the proportion of patients with a 3 month
rolling average of uncorrected serum calcium >10.2 mg/dL (CMS, 2015)
Numerator: Number of patients in the denominator with 3 mo. rolling av.>10.2 mg/dL
Denominator: Number of patient months at the facility during measurement period
Denominator Exclusions (per CMS QIP Technical Specifications)
• Patients <18 years of age
• Patients at the facility for <30 days during the 3 month period
• Incident patients (<90 days on dialysis)
• Patients without at least 1 calcium value during the 3 month period
• Patients not on dialysis (defined by 2728 completion)
• Patients who have died or been discharged prior to the end of the reporting mo.
Data Sources
Data will be collected from CROWNWeb, the data system of record for the ESRD
program. Facilities will enter patient calcium levels into the clinical data fields as
appropriate in the CROWNWeb system. The data is analyzed by Arbor Research, which
holds a CMS contract to provide consulting and research services using analytical tools
for informed decision-making.
Collection Methods
Data will be supplied by two sources: (1) National Coordinating Center reports and (2)
Arbor Research reports. These reports that will pull the clinical data fields from
CROWNWeb showing facility level calcium rates. The NCC reports will supply the
Network with monthly calcium levels and the Arbor Research reports will analyze the
data for a 12-month period.
Project Data Collection Timeline
Data will be evaluated from January of 2017 until the facility either:
1. Improves their calcium scores by a relative ≥25% from baseline for 3 months or
more, or
2. Has exceeded the QIP threshold for the calcium measure for 3 months or more,
completing the PDSA cycle
The Network will have had a minimum of 8 of the 10 facilities reach these goals in
combination by the end of OY1.
Project Timeline:
February
o Evaluate Network Facility QIP scores and calcium levels from CROWNWeb data
supplied by the NCC and Insight to determine facilities to include in the project
o Submit to the COR and CMS Subject Matter Expert (SME)the initial list of facilities
for the project by December 30, 2017 including the rationale for selection of the
facility and level to which the facility represents risk for QIP loss
o Notify facilities of inclusion in the project, provide a copy of the root cause
analysis (RCA) tool to begin evaluating their facility practices related to mineral
metabolism, specifically calcium levels
o Send out RCA to selected facilities to complete and send back to the Network in
early March
o Begin monitoring calcium levels in CROWNWeb for the selected facilities.
o Complete J-attachments on enrolled facilities
o Network to review RCA submissions via conference call with facilities to develop a
mutually agreed upon corrective action plan and PDSA
March 2016 – October 2017
o Monitor facility progress toward goals
o Report progress towards goals on the DIF and Monthly Report
o Continuously evaluate effectiveness of facility interventions & PDSA process
o Follow-up with facilities not progressing toward goal and identify opportunities
for rapid cycle improvement
o Distribute posters to facilities for staff and patients to increase awareness and
importance of calcium management to avoid side effects
o Submit report of facilities meeting goal for three months or longer by the 15th
of
the month to the COR and CMS SME
o Identify and submit report for new facilities entering the project within 10 days of
entry to the COR and CMS SME
October 2017
o Evaluate results from the 10 facilities to determine progress and outcomes
Project Reports
• Monthly quantitative reporting in Dashboard Input Form (DIF)
• Monthly qualitative reporting on the COR Report
• Monthly goal tracking with a report documenting progress toward goal
• J template submission for all facilities who reach goal before the end of the project
year with list of new facilities enrolled with j templates to replace those graduating.
V Expected
Results
The expectation is that facilities involved in this project will improve their mineral
metabolism management, especially related to calcium, by showing a ≥25% (relative
improvement) in calcium scores or by exceeding the ESRD QIP requirements. The
sustenance of this improvement is likely if proper protocols are put into place, and staff
and patients are educated on the importance of mineral metabolism for patient health
and outcomes.
In 2017 ten new facilities were enrolled based on review of Arbor Research data in
combination with final QIP data indicating the need for improvement of their
hypercalcemia rates or loss of QIP points reported in the QIP period November 2015 and
2016. The Network will continue its work on this ESRD Quality Incentive Program (QIP)
Quality Improvement Activity (QIA) with the ten new facilities identified. Based on the
success of this program within the Network in 2016, we expect that at least eight of the
ten facilities enrolled in this project will graduate out.
VI Bibliography/
Appendixes
Bibliography
Centers for Medicare and Medicaid Services. (2015). End-Stage Renal Disease (ESRD)
Quality Incentive Program (QIP) Payment Year(PY) 2018 Final Measure Technical
Specifications. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/ESRDQIP/Downloads/PY-2018-Final-Rule-tech-specs-10-30-
2015.pdf
Centers for Medicare and Medicaid Services. (2015). ESRD Quality Incentive Program,
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/ESRDQIP/index.html
Skugor, M. & Milas, M. (2009). Hypercalcemia. Cleveland Clinic Center for Continuing
Education.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology
/hypercalcemia/
Appendices
1. Appendix A: CHIMPANZEE Provider Pneumonic
2. Appendix B: Patient Poster
3. Appendix C: RCA template
4. Appendix D Notification letter and facility project agreement:
Appendix A: CHIMPANZEE Pneumonic
One clinical quality indicator for patient mineral metabolism management is calcium. An
increased focus has been placed on recognizing and correcting high calcium levels, also known
as hypercalcemia. Hypercalcemia is a higher than normal level of calcium in the blood, which
can affect almost every body system, and is a common comorbidity caused by renal failure.
High levels of calcium in the blood can result in muscle weakness, hypertension, constipation,
anorexia, nausea, fatigue, and pain (Skugor & Milas, 2009). Below is a quick reference for
possible causes of hypercalcemia in your patients. Remember CHIMPANZEES!
Hypercalcemia Pneumonic:
CHIMPANZEES
Calcium Excess (Administration)
Hyperparathyroidism
Immobility / Iatrogenic
Metastasis / Milk-Alkali Syndrome
Paget’s Disease
Addison’s Disease
Neoplasms
Zollinger-Ellison Syndrome
Excess Vitamin D
Excess Vitamin A
Sarcoidosis
Reference: Skugor, M. & Milas, M. (2009). Hypercalcemia. Cleveland Clinic Center for Continuing
Education.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/hyper
calcemia/
Appendix B: Patient Poster
Appendix C: Hypercalcemia RCA tool
Appendix D: Project Inclusion Letter
To: Medical Directors, Nurse Managers, and Facility Administrators
From: Deb DeWalt MSN, RN –Quality Improvement Director
Sue Swan-Blohm (start date 3/7) – Quality Improvement Coordinator
Date: February 15, 2017
RE: 2016 Quality Incentive Program (QIP) Quality Improvement Activity
(QIA)
Project Background
The End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) is a value-based-
purchasing program developed to promote high-quality services for the ESRD
community. This program is designed to alter payment based on the quality of care
received at outpatient dialysis facilities. Those facilities that do not meet or exceed
certain performance standards can received up to a two percent payment reduction for
all services during the applicable payment year (CMS.gov, 2015).
The Centers for Medicare and Medicaid Services (CMS) ESRD QIP includes many clinical
quality indicators. One indicator is the measure of mineral metabolism, including
calcium levels (specifically hypercalcemia). Hypercalcemia can affect almost every body
system, and is a common comorbidity caused by renal failure. High levels of calcium in
the blood can result in muscle weakness, hypertension, constipation, anorexia, nausea,
fatigue, and pain (Skugor & Milas, 2009). For the 2016 project period, CMS has
determined that the primary QIP measure to be evaluated and improved upon would be
hypercalcemia.
________________________________________________________________________
Quality Improvement Activity Description
IPRO ESRD Network 9 of the Ohio River Valley will be implementing CMS designated
activities with facilities chosen for this activity to decrease rates of hypercalcemia at the
facility level. Facilities will be provided with root cause analysis (RCA) templates that the
Network will review with the project team to develop a Plan Do Study Act (PDSA) Plan
for improving rates of hypercalcemia. The project will be conducted beginning in March
of 2017, and will end when the facility reaches either a 25% relative improvement in
rates of hypercalcemia or when the facility exceeds the QIP threshold for this QIP
measure.
Your facility has been chosen to participate in this activity based on the facility rate of
hypercalcemia from November of 2015 through October of 2016. Activities related to
this activity include identifying a root cause for your facility’s hypercalcemia rate, and
then implementing a plan to address some of these causes in collaboration with your
facility team and the Network. A timeline of project activities are noted below and
materials can be found at: https://esrd.ipro.org/qia/qip-hypercalcemia
Please be aware that e-mails about this QIA will be coming soon to those identified as
representatives. Accurate contact information (including name, title, and email address)
is critical to ensure appropriate contact and complete information is received. Thank
you in advance for your assistance and participation in this initiative.
2017 Facility/Network Timeline of Activities February
� The Network will provide a notice of participation in this activity, as well as a
template for evaluating the root cause analysis of hypercalcemia
� Facilities will use the provided RCA template to review hypercalcemia rates with the
interdisciplinary team during QAPI meetings
� The Network will contact a designated Facility Representative to determine a date
and time to meet with the team in March to (1) Review the RCA template and
discuss findings and to (2) provide the facility with a PDSA to improve rates
March – Achievement of Improvement
1. Facilities implement PDSA and provide a summary report to the Network on a
monthly basis any key observations discussed during monthly QAPI by either
2. Periodic conference calls with Network staff to adjust and evaluate PDSA cycle if
not improving.
If you have any questions or comments about the QIA, your involvement, or future
interventions please feel free to contact the Quality Improvement Department by email
at [email protected], we look forward to working with you in this coming year’s
activities!
QIP QIA - PROJECT AGREEMENT
Dear Provider,
The Network shall achieve Centers for Medicare and Medicaid Services (CMS) goals
through the development and implementation of quality improvement activities, such
as the activity noted below. As directed by the Network governing bodies, 2016
performance goals have been set that every dialysis facility is expected to achieve.
Please carefully review the notification letter and attached objectives for the Quality
Incentive Program Quality Improvement Activity (QIP QIA). After review, please
complete the necessary fields, have the Project Lead, Facility Administrator/Nurse
manager, and the Medical Director sign, and return to the Network office via email at
[email protected] by March 20, 2017.
**Please note, regardless of assigned Project Lead, Medical Director and Facility
Administrator/Nurse Manager are responsible for ensuring completion of project
objectives.
In anticipation to your timely response, I thank you for your ongoing support and
cooperation with the Network. If you have any questions or additional information is
needed regarding these goals, please contact Quality Improvement Department at
Sincerely,
Victoria, Cash, MBA, BSN, RN Deborah DeWalt, MSN, RN
Executive Director Quality Improvement Director
CC: MEDICAL DIRECTOR, FACILITY ADMINISTRATOR/NURSE MANAGER, REGIONAL
CONTACT
QIP QIA- PROJECT AGREEMENT
MARCH 2017 – IMPROVEMENT DATE
The undersigned hereby agrees to participate and cooperate with the goals and activities,
including quality improvement projects, as set forth by IPRO ESRD Network (42 CFR Part
494.180.V772 (i) of Centers for Medicare & Medicaid Services (CMS) regulations).
Facility Name (DBA): Medicare Provider # (CCN):
Project Lead Name: Project Lead Title:___________________
Project Lead Signature: ___________________________________Date:
Project Lead Email: _____________________________________________________________
Medical Director:
Medical Director’s Signature: Date:
Medical Director Email:
_________________________________________________________________
Facility Administrator/Nurse Manager
Name:________________________________________________
Facility Administrator/Nurse Manager
Signature:_____________________________________________
Regional Director/Area Administrator:
Phone:__________________
Regional Director/Area Administrator
Email:________________________________________________
Any changes to the above listed contacts must be reported to the Network and corrected in
CROWNWeb within 5 business days to ensure continuity with project implementation and
communications between the Network and Facility. Plans are reviewed periodically, and are
subject to change based on the CMS Statement of Work (SOW).
QUALITY IMPROVEMENT ACTIVITY
• PROJECT OBJECTIVE: Reduce rates of hypercalcemia at the facility level
o PRIMARY PROJECT MEASURES
1. Calcium levels in CROWNWeb
o PRIMARY PROJECT GOALS
1. Reduce rates of hypercalcemia at the facility level by either 25% or to exceed
threshold for QIP
• ACTION ITEMS / FACILTY REQUIREMENTS
o Perform Root Cause Analysis (RCA) of hypercalcemia (March 2017)
o Implement Plan Do Study Act (PDSA) Interventions (April 2016 through improvement)
o Report on progress of PDSA to Network (March 2017 through Improvement)
INFORMATION MANAGEMENT / DATA REPORTING RELATED TO THIS PROJECT
CROWNWeb (CW): Report clinical data and comply with CMS Quality Incentive Program
reporting