ACTION PLAN FOR INCREASING AV FISTULA USE

1. ACTION PLAN FOR INCREASING AV FISTULA USE COMPLETION STEPS Assess your current AV Fistula Outcomes Identify the root causes / barriers to AV Fistula use Identify procedural changes to be made Complete your action plan 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 Calculate the % of your patients dialyzing via AV fistula reviewed by the CQI committee Assess your current AVF outcomes Facility Name: Facility Provider Number: Date:

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

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

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

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

7. Step Three Under which Root Causes in Step 2 did you report the most patients? What procedure changes will you make to address those issues? Identify procedure changes

8. Step Three Here are some tips to help you identify related root causes Identify Procedure Changes