1. Network 11 Quality Update Chris Singer, MAN, RN, CNN December 4, 2008

2. What’s Going on in Network 11? Fistula First Lab data collection MRC Recommended Treatment Guidelines Immunization Involuntary discharge

3. Fistula First

4. We are Improving!

5. Almost there… Final State Approaching 50%

6. We Are Improving!

7. What Are We Doing to Improve? Facility goals Surgeon workshops Data feedback reports QI action plans Patient involvement

8. We Still Have a Ways to Go… September 2008 = 49.4% New Network 11 goal from CMS = 51.3% by 6/30/2009 = 1% per calendar quarter CMS national goal = 66% by 6/30/2009 KDOQI Guideline for prevalent AVFs 65%

9. The Starting Point Where We Were

10. The Target Is Moving –Where We Are

11. Incredible Improvement in 2007

13. 2008 AVF Prevalence Facility Goals Formula used to calculate goals (66% [CMS program goal]) – (facility baseline percent [AVF rate in Q4]) x 20% Project Design –Baseline: December 2007 –Goal to be achieved by December 2008 data –Progress reports sent out quarterly –Action plans requested after 6 months

14. Over Three-Fourths (88.8%) of Facilities on Target to Meet Goal!

15. Early Referral CKD Management ESRD

16. Upper Midwest Coalition Workgroups CKD Management –Strategy: Educate nephrologists and physician extenders ways to use CKD care to improve likelihood of AVF placement prior to dialysis start. CKD Early Referral –Strategy: Use of automatic lab eGFR reporting to alert physicians of early CKD identification. –Train primary care physicians to identify CKD and refer to nephrologist earlier. ESRD –Strategy: State Survey Provider Tool –Develop facility and patient education strategies that will facilitate AVF improvement

17. Coalition Successes  All labs in 5-state region participated in GFR survey with over 2/3 automatically reporting GFR  CKD WebEx conducted for primary care physicians  Vascular access coordinator questionnaire in all Network 11 facilities—WebEx's now being developed  Patient resistance focus groups conducted—new patient resources coming!  Acute dialysis education questionnaire conducted

18. Nephrologist Report Card CMS Form 2728 Patient Data on Vascular Access Information collected included: –Patient population: catheter as sole access for dialysis start –Pre-dialysis nephrology care –Surgeon referral Implemented of model algorithm and education Follow-up data collected

19. Overall, more than 60% of patients in Network 11 are seen by a nephrologist at least 6 months before starting dialysis

20. N = 315N = 1575N = 247N = 1346N = 3639N = 7122

22. Lab Data Collection Elab – 4 th Quarter 2007 (nearly 100% patient sample)

23. Network 11 and the Lab Data Collection Project For Q4 2007 all 18 Networks participated in the project Lab Data Collection project was completely done in house by Network 11 Network 11 has been awarded a contract from CMS to officially conduct this project for Q4 2008

24. National Overall Results

25. Hemodialysis Adequacy

27. Anemia Management

29. Phosphorus Control

31. Medical Review Committee Recommended Treatment Guidelines and Review Criteria

32. 2008 Clinical Indicators with no changes RecommendedBest Practice HD ADEQUACY:  80% of HD patients on three times per week dialysis will have a mean URR of at least  65% or delivered Kt/V of  1.2 > 85% of HD patients on three times per week dialysis will have a mean URR of at least  65% or delivered Kt/V of  1.2 PD ADEQUACY:  80% of PD patients will have a weekly Kt/V of  1.7 > 85% of PD patients will have a weekly Kt/V of  1.7 NUTRITION:  80% of dialysis patients (HD and PD) will have mean serum albumin  the lower limit of normal (LLN), and no more than 10% of patients will have mean serum albumin < 0.9 LLN > 85% of dialysis patients (HD and PD) will have serum albumin  the lower limit of normal (LLN), and no more than 10% of patients will have mean serum albumin < 0.9 LLN BONE/MINERAL:  70% of dialysis patients (HD and PD) will have a mean serum phosphorus of  5.5 mg/dL 8 mg/dL > 80% of dialysis patients (HD and PD) will have a mean serum phosphorus of  5.5 mg/dL 8 mg/dL BONE/MINERAL:  80% of dialysis patients (HD and PD) will have a mean corrected serum calcium concentration of  10.2 mg/dL. > 85% of dialysis patients (HD and PD) will have a mean corrected serum calcium concentration of  10.2 mg/dL. > 75% of dialysis patients (HD and PD) will have a mean corrected serum calcium concentration of  9.5 mg/dL. IMMUNIZATIONS:  90% of patients will receive immunization for influenza  80% of patients will receive immunization for pneumonia  80% of patients without natural immunity will receive immunization for hepatitis B  95% of patients will receive immunization for influenza  85% of patients will receive immunization for pneumonia  90% of patients without natural immunity will receive immunization for hepatitis B ADVANCE CARE PLANNING:  80% of patients will have documentation that advance care planning discussions were conducted within 6 months of initiating dialysis  85% of patients will have documentation that advance care planning discussions were conducted within 3 months of initiating dialysis TRANSPLANT REFERRAL  85% of patients will be assessed by the nephrologist for transplant candidacy or referral within 6 months of initiating dialysis as demonstrated by documentation in the medical record  95% of patients will be assessed by the nephrologist for transplant candidacy or referral within 3 months of initiating dialysis as evidenced by documentation in the medical record

33. Changes for 2008 RecommendedBest Practice ANEMIA MANAGEMENT Facilities should target hemoglobin levels between 11-12 gm/dL. A normal distribution of Hgb levels centered around this target will include:  10% of patients with mean Hgb  10 gm/dL, AND  10% of patients with mean Hgb  13 gm/dL. To be determined following analysis of the Q4 2007 hemoglobin data VASCULAR ACCESS Facility AVF rate will achieve an annual increase that equals at least the specific goal set for that facility*.  65% of prevalent patients dialyze with an AV fistula  10% of prevalent patients are dialyzing with a catheter as sole access > 90 days  5% of prevalent patients are dialyzing with a catheter as sole access > 90 days

34. Elab 2007 Review Process

35. Review Results Q4, 2007 OptionNumberPercent #1 – Best Practice00% #2 – Doing Well4212.1% #3 – Needs some improvement 27178.3% #4 – QI plan required329.2% #5 – On site visit by NW10.02%

36. Network 11 Involuntary Discharges

37. Involuntary Discharge

39. What’s Coming in 2009 QI Projects –Fistula First –Catheter Reduction –Anemia Management –Unused AVF –QAPI CrownWEB

40. 2008 – 09 Projects: Fistula First Goals December 2007 Baseline All facilities with < 65% AVF Used participating Based on CMS formula for Networks Re-measurement using December 2008 data

41. 2008 – 09 Projects: AVF Placed vs. Used Collaborative project with 10 facilities Voluntary participation Baseline data: Fistula First September 2008 Facility-specific goals to reduce unused AVF Interventions include education, quality improvement plans, and data feedback Re-measurement March 2009

42. 2008 – 09 Projects: Catheter Reduction Collaborative project with mentor regional chain of 9 mentor facilities and regional chain of 9 intervention facilities Baseline data: Fistula First September 2008 Facility-specific goals to reduce catheters > 90 days Interventions include education, quality improvement plans, and data feedback Re-measurement March 2009

43. 2008 – 09 Projects: Anemia Management Collaborative project with 8 facilities in MI Baseline data collected September 2008 Facility-specific goals to reduce Hgb 13 (Target range 11 – 12) Voluntary participation Interventions include education, quality improvement plans, and data feedback Re-measurement March 2009

44. 2008 – 09 Projects: Quality Assessment & Performance Improvement Collaborative project with 11 facilities Voluntary participation Based on CFC 8 components of effective QAPI program Interventions include education, quality improvement program assessment, and QI program feedback Baseline QI program assessment October 2008; re- measurement March 2009

45. CrownWEB Patient ESRD data Clinical data Fistula First

46. The mission of the Renal Network of the Upper Midwest is to assess and improve the quality of care provided to patients with end stage renal disease. In Conclusion

47. Questions? csinger@nw11.esrd.net 651-644-9877 csinger@nw11.esrd.net