2020 CMS Priorities, Goals, and Quality Improvement Activities
1
IPRO ESRD Network of New England (Network 1)Network Council Meeting
December 11, 2019
MeetingReminders
• This WebEx will be recorded and slides made available on the Network Website
• All phone lines have been muted to avoid background noise
• Be present and engaged in the presentations
• Be prepared for active participation in the WebEx chat board
p. 2
MeetingReminders
• Be prepared for active participation in polling questions
p. 3
AgendaTopics
• Overview of IPRO ESRD Program: Network 1
• National ESRD Initiatives
• Emergency Preparedness and Management
• Patient Experience of Care
• Patient Engagement
• Quality Improvement Activities (QIA)
• Information Management
• Closing Comments
p. 4
5
Overview of IPRO ESRD Program: Network 1
Danielle Daley, MBAExecutive Director
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ESRDNetworks
7
IPROESRDProgram
132,394ESRDPatients
1,948DialysisFacilities
51TransplantCenters
Network9IN,KY,OH
Network6GA,NC,SC
Network1CT,MA,ME,NH,RI,VT
Patients:15,334Facilities:201Transplant:15
Network2NY
Patients:30,846Facilities:325Transplant:13
Network9OH,KY,IN
Patients:34,570Facilities:650Transplant:14
Network6NC,SC,GA
Patients:51,644Facilities:772Transplant:9
NW2
NW1
IPRO ESRD Network ProgramNetwork Service Areas
MissionStatement
The Mission of the IPRO End Stage Renal Disease (ESRD) Network Program is to promote health care for all ESRD patients that is safe, effective, efficient, patient-centered, timely, and equitable.
p. 8
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State ESRDPatientCensus
#ofDialysisFacilities
#ofTransplantFacilities
Connecticut 4,442 52 2
Maine 1,171 20 1
Massachusetts 7,074 84 9
NewHampshire 1,113 20 1
RhodeIsland 1,168 17 1
Vermont 366 8 1
TOTAL 15,334 201 15Data Source: CROWNWeb 12/2019
Network Demographics By State
10 10
Ownership ESRDPatientCensus
#ofDialysisFacilities
American Renal Associates 1,730 24DaVita 5,035 52Dialysis Clinic Inc. 753 9Diversified Specialty Institutes (DSI) 227 3Fresenius Medical Care 6,102 80Independent 1,334 28US Renal Care, Inc. 58 1Veterans Administration 95 4TOTAL 15,334 201Data Source: CROWNWeb 12/2019
Facility AffiliationBy Organization
Network 1Staff
Danielle R. Daley, MBAExecutive DirectorEmail: [emailprotected] Direct: (203) 285-1212
Agata Roszkowski, LMSWPatient Services DirectorEmail: [emailprotected] Direct: (203) 285-1213
Sarah Keehner, RN, BSN, CNNQuality Improvement DirectorEmail: [emailprotected] Direct: (203) 285-1214
Jaya Bhargava, PhD, CPHQRegional Operations DirectorEmail: [emailprotected]: (203) 285-1215
Cheryl Pettway Sr. Program Support CoordinatorEmail: [emailprotected] Direct: (203) 285-1222
TBDCommunity Outreach CoordinatorEmail: TBD Direct: (203) 285-1223
Nadine Caruthers, LPNQuality Improvement CoordinatorEmail: [emailprotected]: (203) 285-1224
Krystle GonzalezCustomer Service ManagerEmail: [emailprotected] Direct: (203) 285-1225
p. 11
CMS ExpectationsRole of the Network
• Improve quality of care for ESRD patients
• Provide assistance to ESRD patients and providers
• Encourage patient engagement
• Evaluate and resolve patient grievances
• Collect data to measure quality of care
• Support emergency preparedness and disaster response
p. 12
Technical AssistanceWe’re Here to Help
• The Network has tools to help with quality improvement activities–Infection prevention–Catheter reduction–Transplant referrals
• The Network provides technical assistance–Data reporting–Patient engagement–Access to care barriers
p. 13
–Benefits of home dialysis–Peer mentoring–Vocational rehabilitation
–Quality Incentive Program (QIP)–Patient/provider conflict–Patient safety
• The Network sponsors educational opportunities–Face-to-Face Meetings–Webinars–Conference Calls
• The Network shares data–Comparative Network, state, and facility level–Incidence, prevalent, and demographic statistics–Annual Report
p. 14
Technical AssistanceWe’re Here to Help
AreYouReady?
We’reMoreThanJustaNumber
Let’sTestYourMemory
DoYouKnowYour
Network?
PollingQuestion
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Emergency Preparedness and Management
Agata Roszkowski, LMSWPatient Services DirectorEmergency Management Coordinator
Emergency ManagementThings to Know
Facility Reporting/Tracking • Report Facility Status (Open/Closed/Altered)
• Report patient access to care
• Contact the Network to assist with local OEM coordination efforts
Prepare Patients for an Emergency• Be prepared patient worksheet
• 3-Day Emergency Diet
Prepare Your Facility for an Emergency• Technical assistance to facilities to develop
feasible, comprehensive emergency/disaster plansp. 17
Emergency PreparednessOverview
The Network 1 Emergency Preparedness and Management Plan Roles during an emergency Mobilization and response of the Network Providing and maintaining support Quality management of the emergency
p. 18
AreYouReady?FrequencyEmergency
Planning
WeWanttoHearFrom
You
PollingQuestion
20
Patient Experience of Care
Agata Roszkowski, LMSWPatient Services Director
Patient Experience of CareGrievances Definition and the Network’s Role
• What is a grievance?
• Network’s Role–Facilitator–Expert Investigator–Educator–Quality Improvement Specialist–Advocate–Referral Source
p. 21
Patient Experience of CareGrievance Management and Best Practices
• Development/support robust grievance process
• Foster environment that encourages patients, family members, care partners to voice their opinions
• Encourage positive resolution focused outcomes
• Establish an anonymous grievance process
• Grievance Educational Materials–Network Grievance Poster –Forum Grievance Toolkit p. 22
CMS Expectations:Network Responsibilities
• The Network assists with patient grievances–Evaluate and resolve grievances using a patient centered approach –Follow CMS guidelines, document all Network steps of grievance
resolution, and adhere to timeframes –Perform quality of care reviews using an interdisciplinary approach
(LMSW / RN)–When necessary, refer cases to the Grievance Committee or Medical
Review Board for review
p. 23
CMS Expectations:Support for Access to Care Concerns
p. 24
Reasons for Access to Care Cases:• At-Risk of Involuntary Discharge
• Involuntary Discharge
• Involuntary Transfer
• Failure to Place
• Loss to Follow Up
Patient Experience of CareCommunity Resources
• InvoluntaryDischargeResources–ThreatsareNotOkayHerePoster
–InvoluntaryDischargeGuide
• GrievanceManagementProcessResources
–DialysisPatientGrievanceToolkit
• CommunicationResourcesforstaffandpatients–ApplyingNetForwardEnergyinPatientCareWebinar
–RelationshipCenteredCommunicationWebinar
p. 25
AreYouReady?ManagementDisruptive
Patient
WeWanttoHearFrom
You
PollingQuestion
27
Patient Engagement
Agata Roszkowski, LMSWPatient Services Director
Patient Advisory Committee (PAC)Structure and Function
• PAC members are :–Promote communication between patients and staff–Inform patients about the ESRD Network–Reach patients in the New England area
• PAC members are selected and nominated by facility staff
p. 28
Patient Advisory Committee (PAC)Patient Facility Representative
• Involved in the development of QIA interventions and resources
• Encouraged to participate in intervention implementation at the facility
• Patients are asked to:–Consider becoming a Peer Mentor–Share their ESRD journey story with others–Attend meetings led by the Network–Participate in national meetings and technical expert
panels
p. 29
Patient Engagement Goals
• Utilizing Peer to Peer model
• Increase self management behaviors
• Social support
• Health related quality of life and self-efficiency
p. 30
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National ESRD Initiatives
Danielle Daley, MBAExecutive Director
ESRD Statement of WorkDecember 2019 - November 2020
Background & Purpose• To delineate tasks to be conducted by each End Stage Renal
Disease (ESRD) Network Organization contractor in support of achieving national quality improvement goals and statutory requirements as set forth in Section 1881 of the Social Security Act and the Omnibus Budget Reconciliation Act of 1986
• Tasks in this SOW are intended to align Network activities with:– Department of Health and Human Services (HHS) National
Quality Strategy (NQS)– HHS Secretary Priorities – Centers for Medicare & Medicaid Services (CMS) goals
p. 32
ESRD Statement of WorkDecember 2019 - November 2020
HHS Secretary’s Priorities1. Opioid Crisis
2. Health Insurance Reform
3. Drug Pricing
4. Value-Based Care
p. 33
ESRD Statement of WorkDecember 2019 - November 2020
CMS Goals1. Empower patients and doctors to make decisions about their
health care
2. Usher in a new era of state flexibility and local leadership
3. Support innovative approaches to improve quality, accessibility, and affordability
4. Improve the CMS customer experience
p. 34
ESRD Statement of WorkDecember 2019 - November 2020
Areas of Focus • Aligned with Executive Order for Advancing American Kidney Health
(AAKH)–Reduce the number of Americans developing ESRD by 25% by 2030–Doubling the number of kidneys available for transplant by 2030–80% of new ESRD patients in 2025 either receiving dialysis at home or
receiving a transplant
p. 35
ESRD Statement of WorkDecember 2019 - November 2020
Collaborations• National Coordinating Center (NCC)
• Kidney Community Emergency Response Program (KCER)
• State Survey Agencies
• National Accreditation Agencies
• Quality Innovation Networks (QIN-QIOs)
• Hospital Improvement Innovation Network (HIIN)
• Clinical Quality Improvement Contractors (CQICs)
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Quality Improvement Initiatives
ESRD Statement of WorkChanges
Changes to Quality Improvement Activates • There are Network wide goals
• No facility inclusion or exclusion criteria for any project
• All facilities are expected to participate in each activity
p. 38
ESRD Statement of WorkDecember 2019 - November 2020
National Coordinating Center (NCC) Learning and Action Network (LAN) Events • Bi-monthly webinars, hosted on the first three Tuesdays of a month from
3:00- 4:00 pm starting January • Recordings of the event will be available on the NCC website 10 business
days after the event • CMS Certification Number (CCN) are required at registration to get credit
for attending • 1 free continuing education credit for nurses and technicians available for
each call • 18 total CEs available
p. 39
ESRD Statement of WorkDecember 2019 - November 2020
Learning & Action Networks (LANs)• Patient Experience of Care
• Bloodstream Infections (BSI)
• Home Dialysis
• Patient and Family Engagement (PFE)
• Transplant
• Population Health Focused Pilot QIA (PHFPQ)
p. 40
ESRD Statement of WorkMonthly Communication
Monthly Data Collection Tool • Made available to facilities five business days prior to last day of
the month
• Due to Network on the last working day of each month
Provide Insider • Monthly newsletter that will be disseminated on the first Tuesday of
each month
• Contain links to education resources for QIAs, QIP, and webinar registration
p. 41
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Making Care Safer by Reducing the Harm Caused in the Delivery of Care
Sarah Keehner, RN, BSN, CNNQuality Improvement Director
Reducing Harm When Delivering CareReduce Infections
Background• CMS has a goal to decrease the 2016 national infection rate 50%
by 2023
• Contains 5 sub-projects:–Bloodstream Infection Reduction–Long Term Catheter Reduction– Implementation of Center for Disease Control and Prevention Core
Intervention –Completion of the National Healthcare and Safety Network Annual Event
Surveillance Training – Improving process for communicating positive blood cultures between
hospitals and dialysis facilities
p. 43
Reducing Harm When Delivering CareReduce Rates of Bloodstream Infections
Objectives • To reduce the number of positive blood cultures reported in NHSN by 20%
across New England
Project Period• Baseline: January – June 2019
• Re-measurement: January – June 2020
Requirements• Utilization of CDC Core Interventions
• Conduct Root Cause Analysis (RCA)
• NHSN Annual Dialysis Event Surveillance Training p. 44
Reducing Harm When Delivering CareCore Intervention for BSI Prevention
p. 45
AreYouReady?UtilizationCDCCore
Interventions
WeWanttoHearFrom
You
PollingQuestion
Reducing Harm When Delivering CareLong Term Catheters Rate Reduction
Objective • To reduce the Network utilization rate of Long Term Catheters by 0.25%
Project Period• Baseline: July 2019
• Re-measurement: CROWNWeb data available in October 2020
Requirements• Use peer to peer to share experience with catheter related infections
• Improving the communication with vascular surgeons and interventional radiologist
• Improving surveillance of fistula and grafts p. 47
Reducing Harm When Delivering CareEnhancing Health Information Exchange
Objective • To enhance the process for communicating positive blood cultures
between hospitals and dialysis facilities
Requirements• The Network shall obtain documentation from the facility that use of the
HIE platform or other evidence-based highly effective information transfer system is successful. This may include policy and procedure or less formal evidence of a system.
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Promoting Modalities to Support AAKH
Nadine Caruthers, LPN Quality Improvement Coordinator
Promote Appropriate Home DialysisIncrease Rates of Patients in Home
Objective • To increase the Network home dialysis rate by 2.5%
Project Period• Baseline: October 2019 CROWNWeb Data
• Re-measurement: October 2020 CROWNWeb Data
Requirements• Encourage facilities to incorporate the seven steps leading to home dialysis
training into patient education, facility practice, and facility QAPI process
• NCC Home Dialysis LAN participation
p. 50
Promote Appropriate Home DialysisIncrease Rates of Patients in Home
Track and report to CMS the number of patients in each of the 7 steps each month:1. Patient interest in home dialysis2. Educational session to determine the patient’s preference of home
modality3. Patient suitability for home modality determined by a nephrologist
with expertise in home dialysis therapy4. Assessment for appropriate access placement5. Placement of appropriate access6. Patient accepted for home modality training7. Patient begins home modality training
p. 51
Promote Appropriate Home DialysisAvailable Resources
p. 52
Improve Transplant CoordinationIncrease Rates of Patients on Waitlist
Objective • Increase the number of patients on the kidney transplant waitlist by 1.25%
Project Period• Baseline is October 2019 UNOS Data
• Re-measurement: October 2020 UNOS Data
Requirements• Monitor/track patient progress through five steps leading to placement on
transplant waitlist
p. 53
Improve Transplant CoordinationIncrease Rates of Patients on Waitlist
Track and report to CMS the number of patients in each of the 5 steps each month:1. Patient interest in transplant2. Referral call to transplant center3. First visit to transplant center4. Transplant center work-up5. On waiting list or evaluate potential living donor
p. 54
Improve Transplant CoordinationAvailable Resources
p. 55
AreYouReady?
ForPatients
EarlyEducation
WeWanttoHearFrom
You
PollingQuestion
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Quality Improvement Tools and Reporting
Sarah Keehner RN, BSN, CNNQuality Improvement Director
Quality Improvement Tools Root Cause Analysis and Plan-Do-Study-Act
RCA• Conduct a RCA to identify the barriers for each initiative
• Many ways to conduct an RCA• 5 Why’s • Fishbone
• If a facility’s dialysis organization already utilizes a RCA tool then that template many be used
PDSA• Utilize the PDSA cycle to test the processes initiated to overcome
barriers
p. 58
Quality Improvement ToolsPDSA Template
p. 59
Quality Improvement ToolsEmpathy Mapping
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Data Management
Jaya Bhargava, PhD, CPHQRegional Operations Director
CMS Expectations: Facility ResponsibilitiesESRD Data Collection Systems
• CMS Designated Data Collection Systems–CROWNWeb
http://mycrownweb.org/assets/crownweb-dm/dm_guidelines/–National Healthcare Safety Network (NHSN)
https://www.cdc.gov/nhsn/dialysis/event/index.html• ESRD Outcome Reports
–Quality Incentive Program -https://cportal.qualitynet.org/QNet/pgm_select.jspo Performance Score Reports and Certificates
–Dialysis Data - http://www.dialysisdata.orgo Dialysis Facility Reports and Dialysis Facility Compare
–In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAPHS) - https://ichcahps.org/o Third Party Vendor p. 62
CMS Expectations: Network ResponsibilitiesData Reporting Assistance
• Educate facilities to follow CMS Data Management Guidelines
• Inform providers of upcoming deadlines
• Streamlined process to inform facilities of missing data
• Working towards 100% patient level data submission compliance
– CROWNWeb– NHSN
p. 63
ESRD QIP
NHSN
CROWNWeb
CMS ExpectationsCROWNWeb Data Quality Goals
• CMS issued CROWNWeb Data Quality Goals
• Established key indicators and goals align with Data Management Guidelines
• Used to assess facility data submission and performance
p. 64
CROWNWeb Data Reports from Network• Review reports and submit missing data in CROWNWeb
• All data submissions are time sensitive but highest priority with immediate action required are for:
–Missing Clinical Data reports - clinical month closes and cannot be changed–Facility Personnel Report – ensures the most current contact information is
available for your facility
• Your Facility Staff receive reports in these areas on a regular basis.
NEVER send PHI or PII via email to the Network
p. 65
CROWNWeb Facility Personnel
p. 66
• Monthly your CROWNWeb Data contact receives report
• Review and ensure Facility Personnel in CROWNWeb is complete and accurate
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Technical AssistanceKnowledge Base and Customer Portal
• Platform for resolving and tracking requests for data assistance from facilities in our region
• Review articles related to different support topics• http://help.esrd.ipro.org/support/home
• Submit a request for data assistance directly from the website or using Email address below
• [emailprotected]
• Submit ticket for One-on-One Technical Assistance:• Use of WebEx “Meet Now” method for real-time assistance
p. 67
REDCap• REDCap is a secure web application used for building and
managing online surveys
• REDCap is provisioned by IPRO via Amazon Web Services (AWS) GovCloud (HIPPA compliant)
• It is used to collect virtually any type of data.
• It can be used for surveys containing patient data.
• Automatic reminders are set up
• Act on the survey if a reminder is received.
p. 68
AreYouReady?Fresdesk
CustomerService
SupportPortal
WeWanttoHearFrom
You
PollingQuestion
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Closing Comments
CMS Expectations Facility Responsibilities
• Participate in Network Quality Improvement Activities (QIAs)
• Inform patients of available Network resources–Grievance resolution–Educational materials–Peer-to-peer mentoring
• Notify the Network of major events–Facility emergencies–Leadership changes
• Respond to inquiries and requests for information
p. 71
CMS ExpectationsFacility Responsibilities
• Timely submission of data
• Keep facility personnel information updated in CROWNWeb
• Discuss challenges/barriers
**CommunicatewiththeNetwork**p. 72
ESRD Network of New England Websitehttp://network1.esrd.ipro.org
p. 73
IPRO ESRD Program Facebook Pagehttps://www.facebook.com/IPROESRDProgram
p. 74
ESRD Network of New England2020 Educational Opportunity
Home Modalities Learning Series • Spring 2020
• A Center Experience: The Impact of Transitional Start Unit• HHD: Adequacy, Prescriptions and Outcomes• Transitions in Care: A patient road map for transitioning prevalent from
In-Center to Home
Kidney Discard and High Kidney Donor Profile Index (KDPI) Webinar• Spring 2020
8th Annual ESRD New England Fall Conference• October 8, 2020
– Mohegan Sun, Uncasville, Connecticutp. 75
Action ItemsDuring the Month of December
• Conduct “Know Your Network” in-service with all dialysis facility staff
• Identify at least one patient and/or family member or caregiver to participate in facility and Network engagement activities
• Review facility personnel in CROWNWeb and update individual records accordingly
• Educate dialysis staff about the facility’s CMS Certification Number (CCN)
• Conduct Root Cause Analysis (RCA) to identify barriers to reaching successful outcomes regarding the 2020 initiatives for improving kidney health
p. 76
p. 77
Presentation TemplateDraft for Review
April 6, 2017
p. 1
Corporate Headquarters1979 Marcus AvenueLake Success, NY 11042-1002
www.ipro.org
For more information:Danielle Daley, MBA Jaya Bhargava, PhD, CPHQExecutive Director Regional Operations Director(203) 285-1212 (203) [emailprotected] [emailprotected]
Sarah Keehner, RN, BSN, CNN Agata Roszkowski, LMSWQuality Improvement Director Patient Services Director(203) 285-1214 (203) [emailprotected] [emailprotected]