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Clinical Indicator Goals: Are You on Target?

Clinical Indicator Goals: Are You on Target?. Svetlana (Lana) Kacherova, QI Director July 30 & 31, 2008. Health Care Quality Improvement Program (HCQIP). The Center for Medicare & Medicaid Services (CMS) contracts with 18 ESRD Network Organizations throughout the United States

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Clinical Indicator Goals: Are You on Target?

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  1. Clinical Indicator Goals: Are You on Target? Svetlana (Lana) Kacherova, QI Director July 30 & 31, 2008

  2. Health Care Quality Improvement Program (HCQIP) • The Center for Medicare & Medicaid Services (CMS) contracts with 18 ESRD Network Organizations throughout the United States • The ESRD Networks perform oversight activities to assure appropriateness of services and protection for ESRD patients. • This approach has been named the ESRD Health Care Quality Improvement Program (HCQIP)

  3. Number of Prevalent ESRD Patients in the US

  4. ESRD Network National Goals • Improve the quality of health services & quality of life for ESRD beneficiaries • Improve data reporting, reliability, & validity between providers, NWs, and CMS • Evaluate and resolve patient grievances • Support the marketing, deployment, and maintenance of CMS approved software CMS, ESRD NW Organization Manual

  5. ESRD Network National Goals • Establish & improve partnerships & cooperate activities with • Providers & Owners • NWs, Quality Improvement Organizations (QIOs) • State Survey Agencies • Professional Groups & Patient Organizations CMS, ESRD NW Organization Manual

  6. Network 18 Mission Statement To provide leadership and assistance to renal dialysis and transplant facilities in a manner that supports continuous improvement in patient care, outcomes, safety and satisfaction.

  7. Network 18 Definition of Quality “Doing the right thing correctly the first time.”

  8. Patients In Our Network(2006/2007 Annual Report) • How Many? • Incident – 8,428 / 6,819 • Prevalent – 27,600 / 29,131 • Deaths – 5,369 / 5,432

  9. Network 18 Patient Distribution by Modality

  10. Delivering Care to Dialysis Patients • Dialysis Facilities – (n=305) • Ownership • Large Corporate (LDO) - 157 • Non-Corporate (Independent) - 148 • Location • Freestanding • Hospital

  11. Goals Established by the ESRD Network based on: • Past performance • CMS thresholds • NKF/KDOQI Clinical Practice Guidelines • The expectation is that facilities not meeting expected performance standards will develop internal quality monitors to promote continuous improvement

  12. Clinical Performance Goals • Provides measurement tool to assess facility patient care processes and outcomes, and identify opportunities for improvement. • The Network goal is to combine efforts with renal facilities to improve performance in the delivery of quality patient care

  13. ESRD Clinical Performance Measures (CPM) Project: • National effort led by CMS and 18 ESRD Networks that started in 1994 • Random sample of patients that are representative of each Network • For HD patients – (October-December 2006) • For PD patients – (October 2006- March 2007)

  14. Five Major Domains of Care: • Adequacy of Dialysis • Anemia Management • Nutritional Status • Bone and Mineral Metabolism • Vascular Access

  15. Adequacy of Dialysis • Numerous outcome studies have demonstrated a correlation between the delivered dose of hemodialysis and patient mortality and morbidity • Pre and post-dialysis blood urea nitrogen (BUN) levels were drawn and reported to calculate URR results • Kt/V was calculated using the pre- and post BUN, post dialysis weight, and time on dialysis

  16. Adequacy of Dialysis: adult HD pts (URR) The Network’s goal is to achieve 88% of patients with a URR ≥ 65%

  17. Adequacy of Dialysis Adult HD pts (Kt/V) The Network’s goal is to have 88% of patients with a Kt/V ≥ 1.2.

  18. 2007 Annual Report: Opportunities to Improve Adequacy • 10% of patients did not have a mean Kt/V > 1.2 during the three-month study period

  19. 2007 CPM results U.S. Adult PD patients: Adequacy of Dialysis

  20. 2007 CPM Results Pediatric HD Patients: Adequacy Opportunities to improve Clearance: 10% of patients did not have a mean sp Kt/V > 1.2 during the three-month study period

  21. 2007 CPM Results Pediatric PD Patients: Clearance Opportunities to improve Clearance: 13% of patients did not have a mean weekly Kt/V > 1.8 during the six-month study period

  22. Network 18 Adequacy Trends (HD & PD Patients) – LDC 2007

  23. Dialysis Session Time: NW 18

  24. Anemia Management Adult HD pts (Hgb) The Network’s goal is to maintain 85% of patients with Hgb > 11.0

  25. 2007 CPM results U.S. Adult PD patients: Anemia Management

  26. 2007 Annual Report: Opportunities to Improve Anemia Management • 16% of patients did not have a mean HGB > 11.0 (g/dl) during the three-month study period • 21% of patients did not have a mean TSAT > 20% and 5% of patients did not have a mean Serum Ferritin > 100 ng/ml

  27. 2007 CPM Results Pediatric HD Patients: Anemia Management Opportunities to improve Anemia: 31% of patients did not have a mean Hgb > 11.0 g/dl during the three-month study period

  28. 2007 CPM Results Pediatric PD Patients: Anemia Management Opportunities to improve Anemia: 29% of patients did not have a mean Hgb > 11.0 g/dl during the six-month study period

  29. Network 18 Anemia Management Trends (HD & PD Patients) – LDC 2007

  30. Iron Studies

  31. Nutritional Status Adult HD patients The Network’s Goal for dialysis units is to maintain 84% of patients with a mean serum albumin ≥ 3.5/3.2 gm/dL (BCG/BCP).

  32. 2007 Annual Report: Opportunities to Improve Serum Albumin • 66% of patients did not have a mean serum albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period • 19% of patients did not have a mean serum albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period

  33. 2007 CPM results U.S. Adult PD patients: Serum Albumin Opportunities to improve Serum Albumin: 81% of patients did not have a mean Serum Albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period 37% of pts did not have a mean Serum Albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period

  34. 2007 CPM Results Pediatric HD Patients: Serum Albumin Opportunities to improve Serum Albumin: 51% of patients did not have a mean Serum Albumin > 4.0/3.7 g/dl (BCG/BCP) during the three-month study period 18% of pts did not have a mean Serum Albumin > 3.5/3.2 g/dl (BCG/BCP) during the three-month study period

  35. Network 18 Nutrition Management Trends (HD & PD Patients) – LDC 2007

  36. Bone and Mineral Metabolism: Adult HD pts)

  37. 2007 CPM results U.S. Adult PD patients: Bone and Mineral Metabolism

  38. Network 18 Calcium Management Trends (HD & PD Patients) – LDC 2007

  39. Network 18 Phosphorus Management Trends (HD & PD Patients) – LDC 2007

  40. 2007 CPM Results: Vascular Access

  41. 2007 Annual Report: Opportunities to Improve Vascular Access • 58% of incident patients and 55% of all patients were not dialyzed with an AVF during their last hemodialysis session Oct-Dec 2006 • 32% of patients with an AVF or AVG did not have their access routinely monitored for the presence of stenosis during the three month study period

  42. ESRD Network 18 – Vascular Access Trends 1995-2006

  43. What is the most visible QI project in Network 18? • Fistula First (Fistula First Breakthrough Initiative)

  44. “Fistula First” GOAL Goal is to maximize autogenous AVF construction & success rate….. To achieve in the shorter term (2006) the initial K/DOQI minimum benchmark of AVF use in 40% of prevalent patients…. And in the long-term (2009), a 66% AVF rate in prevalent patients Additional Goal: Reduce Catheter Use!

  45. Improvement in Prevalent AVF Rates by ESRD Network FFBI AVF goal 66%

  46. Fistula First Goals (AVF Rates) • CMS goal – 66% by June 30, 2009 • Yearly Network 18 goal – 55.1 % by June 30, 2009 • Yearly Network Stretch Goal – 56.0% by June 30, 2009 • May 2008 AVF rates: NW 18 – 53.0% US – 49.7%

  47. Routine CQI Review of vascular access Timely referral to nephrologist Early referral to surgeon for “AVF Only” Surgeon Selection Full range of appropriate surgical approaches Secondary AVFs in AFG patients AVF evaluation/placement in catheter pts Cannulation training Monitoring and maintenance Continuing Education Outcomes feedback Tools & Best Practices:Fistula First Change Concepts

  48. New Conditions for Coverage: QAPI (Quality Assessment and Performance Improvement) • Condition Level • Interdisciplinary Team • Process continuous and on-going • Outcome focused: use community accepted standards and targets • Include patient satisfaction, infection control, medical injuries and medication errors • Plan/Do/Check/Act: Close the loop!

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