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Quality Improvement Overview

A primary goal of the ESRD Networks is to improve the quality of health care services provided to ESRD beneficiaries. Network 8 utilizes various strategies to achieve this goal, such as development and coordination of quality improvement projects, provision of data feedback reports, offer of technical assistance by Network 8 QI staff and Medical Review Board, and provision of educational opportunities and materials.

Areas in need of improvement in Network 8 are identified by:

  • CMS direction
  • Patient and facility communications
  • Various data collections and reports
  • State surveyor and QIO collaborations
  • Input from renal community and Network 8 boards

These areas may be addressed through general measures for all facilities, such as posting educational materials on the website, or by specific Network intervention with targeted facilities, practitioners or regions.

The CMS Conditions for Coverage require each facility to participate in the Network CQI activities, as well as establish their own Quality Assessment and Performance Improvement (QAPI) program to include, as described in the Interpretive Guidance:

  • Monitoring data/information
  • Prioritizing areas for improvement
  • Determining potential root causes
  • Developing, implementing, evaluating and revising plans that result in improvements in care

Quality of care issues to be addressed by facilities include, but are not limited to, dialysis adequacy, nutritional status, mineral metabolism and renal bone disease, anemia management, vascular access, medical injuries and identification of medical errors, hemodialysis reuse program (if applicable), patient satisfaction and grievances, and infection control issues.

Additional information and assistance with QAPI activities may be obtained by contacting the QI staff at the Network office.

Goals for Clinical Performance Measures/Quality Indicators

Network 8 endorses the CMS Quality Incentive Program goals in lieu of setting additional Network-specific goals.

Payment year 2020 Achievement Thresholds, Benchmarks, and Performance Standards

Measure Achievement Threshold (15th percentile) Benchmark (90th percentile) Performance Standard
Kt/V Dialysis Adequacy

91.09%

98.56%

95.64%

Vascular Access Measure
  • AVF

53.95%

79.90%

65.98%

  • Catheter

17.22%

3.11%

9.40%

Hypercalcemia

2.41%

0%

0.86%

NHSN Bloodstream Infection*

1.598

0

0.740

Standardized Readmission Ratio*

1.273

0.629

0.998

Standardized Transfusion Ratio*

1.444

0.429

0.889

Standardized Hospitalization Rate*

1.249

0.670

0.967

ICH CAHPS Survey
Nephrologists' Communication and Caring
57.36%
78.09%
67.04%
Quality of Dialysis Center Care and Operations
53.14%
71.52%
61.22%
Providing Information to Patients
73.31%
86.83%
79.79%
Overall Rating of Nephrologists
49.33%
76.57%
62.22%
Overall Rating of Dialysis Center Staff
48.84%
77.42%
62.26%
Overall Rating of the Dialysis Facility
52.24%
82.48%
66.82%

*On these measures, a lower rate indicates better performance.

 

5 Diamond Patient Safety Program

logo-5-diamondIn order to encourage patient safety values, Network 8 announces availability of the voluntary 5-Diamond Patient Safety Program. Initially developed and implemented in the Network of New England (NW1) and the Mid-Atlantic Renal Coalition (NW5), this program is designed to assist dialysis units with specific areas of patient safety that may be in need of improvement and consistency. Click here to read about the benefits of participating in this self-paced recognition program.

Med Watch Alert

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