1. ACTION PLAN FOR INCREASING AV FISTULA USE COMPLETION STEPS 1.Assess your current AV Fistula Outcomes 2.Identify the root causes / barriers to AV Fistula use 3.Identify procedural changes to be made 4.Complete your action plan 5.Return worksheets and Action Plan to the Network by January 9, 2009 Complete all enclosed forms and return ALL information to the Network office by January 9, 2009

2. Step One Assess your current AVF outcomes Calculate the % of your patients dialyzing via AV fistula reviewed by the CQI committee 1.Calculate your current fistula rates 2.Use the enclosed graph to plot your current fistula rate Month Total patients dialyzing in your facility as of the end of the month Of the patients in the first column, what percentage dialyzes via the following access types? AV FistulaAV GraftCatheter/Port #%#%# % July 08 Sep 08 Oct 08 % = # of patients dialyzing via the access divided by total number of patients Facility Name: Facility Provider Number: Date:

3. Step Two Identify primary root cause 1.Count & review each of your patients who did not dialyze via AVF on the last day of November 2008 2.Follow the algorithm to determine the reason (root cause) for each patient not having an AVF. 3.Count each patient only once. Patient not dialyzing via AVF (cannulated with 2 needles) Does patient have an AVF in place that is not yet mature enough for use? No Yes Maturation time within surgeon’s expectation? Tally # of patients: Yes Tally # of patients: Tried to cannulate but inadequate BFR? No Yes Tried to cannulate but had adverse event (blown, swelling)? Tally # of patients: No Yes Network 6 AVF Root Cause & QI Tool AVF needs intervention, not yet scheduled? Tally # of patients: Yes AVF had intervention and needs time to heal? Tally # of patients: Yes No AVF needs intervention, but patient refuses? Tally # of patients: Yes No If no, Continue to next page Tally # of patients: Other reason that AVF is not mature within surgeon’s expected time No

4. Does patient have a matured AVF in place that is not being used? No Yes Does patient refuse to have AVF cannulated? Tally # of patients: Yes Tally # of patients: Does Nephrologist want to wait longer? No Yes Does Surgeon want to wait longer? Tally # of patients: No Yes Network 6 AVF Root Cause & QI Tool Is AVF too deep or poorly located to cannulate? Tally # of patients: Yes Does nephrologist prefer to continue using functional AVG? Tally # of patients: Yes No Does nephrologist prefer to continue using functional catheter? Tally # of patients: Yes No If no, Continue to next page Does patient prefer to use cathete r? Tally # of patients: Yes No Is AVF ready to use, but staff unaware of status? Tally # of patients: Yes No Tally # of patients: No Functional AVF is not being used for Other reason Patient refuses Cannulation for Other reason

5. Is AVF unsuitable or not possible? Tally # of patients: LRD/LUD transplant scheduled? Starting PD within 30 days? Patient has no viable AVF sites Tally # of patients: Yes No Yes Network 6 AVF Root Cause & QI Tool Is pt dialyzing via functioning AVG with no AVF placed? Tally # of patients: Nephrologist requested that the AVG be placed? Surgeon chose to place the AVG? Tally # of patients: Yes No Tally # of patients: If no, Continue to next page No Patient not an AVF candidate for Other reason Patient dialyzing via AVG for Other reason

6. Is pt dialyzing via functioning Catheter with no AVF placed? Tally # of patients: Has patient refused AVF placement? Is patient waiting for an AVF referral? Is patient scheduled for AVF surgery? Tally # of patients: Are patient transportation issues preventing AVF consult/surger y? Tally # of patients: Yes No Yes Network 6 AVF Root Cause & QI Tool Tally # of patients: Yes Is patient scheduled for AVG surgery? Tally # of patients: No Yes Are other issues preventing AVF consult/surger y? No If you have patients not falling into one of these root causes, contact the Network office for technical assistance. Info@nw6.esrd.netInfo@nw6.esrd.net / 919.855.0882 No Move on to Step Three

7. Step Three Identify procedure changes Under which Root Causes in Step 2 did you report the most patients? What procedure changes will you make to address those issues? Find the box on your root cause assessment with the highest number of patients reported. State that as a problem statement. Examples: “73% of our patients have not been referred for an AVF.” “12% of our patients have a failed AVF each month” “26% of our patients have refused to have an AVF placed.” Repeat for the 2nd and 3rd most frequently reported causes. Root Cause #1: (Example - Cannulation training scheduled) What procedure(s) will you implement or change to address this root cause? Root Cause #2: (Example – Process to refer new patients to surgeons upon admission for A-V fistula) What procedure(s) will you implement or change to address this root cause? Root Cause #3: (Example – Process to convert failed grafts to A-V fistula) What procedure(s) will you implement or change to address this root cause?

8. Step Three Identify Procedure Changes Here are some tips to help you identify related root causes Patients have no viable AV Fistula Sites  What can you do to preserve existing AVFs for other patients?  Do you have a program for cannulation training and retraining?  Seek surgeon able to place AVF  Do you conduct vessel mapping?  Have you trained staff on the buttonhole technique? Patients have fistulas placed; waiting for them to mature  What are your procedures for AVF evaluation and revision referral?  What is your new patient referral program?  Do you have a program for pre-ESRD education and fistula placement? Patients have functioning grafts instead of AV Fistula  Are these recently placed?  Is/are your surgeon(s) fistula-friendly?  What is your surgeon referral procedure?  Are you converting failed grafts to fistulas? Patients refuse to have fistula placed or refuse to let you cannulate their fistula  What education does your facility provide to patients? To staff?  Is there a common theme on why patients refuse?  What role does the nephrologist play in counseling patients on fistula placement?  Do you promote self-cannulation?  Do you use the buttonhole technique?  Do you use topical ointment? Patients haven’t been referred for AVFs  What is the procedure for referring patients?  What is the procedure for following up on referrals and surgeon appointments?  Who is responsible for follow up? Patients can’t get transportation to surgeon  What assistance do you provide?  Is the Social Worker involved in AVF referral?  Does your referral process address transportation issues?  Does your referral process include involving the family and/or nursing home in transportation?