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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.

Current Network 8 Quality Improvement Projects

  1. Bloodstream Infections QIA
  2. Modality QIA
  3. Vocational Rehabilitation QIA
  4. Facility and Patient Engagement QIA

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 2022 Achievement Thresholds, Medians, and Benchmarcks

Measure Achievement Threshold (15th Percentile of National Performance)* Median (50th percentile of National Performance)* Benchmark (90th Percentil of National Performance)*
Kt/V Composite

93.10%

97.04%

99.15%

Standardized Fistula Rate

52.52%

63.76%

76.16%

Catheter Rate

18.57%

11.22%

5.07%

Hypercalcemia

1.77%

0.58% (0.59%)

0.0%

NHSN Bloodstream Infection*

1.365

0.604

0

Standardized Readmission Ratio*

1.268 (1.269)

0.998

0.692 (0.641)

PPW

8.12%

16.73%

33.90%

Standardized Hospitalization Ratio*

1.248

0.967

0.670 (0.677)

ICH CAHPS Survey
Nephrologists' Communication and Caring
58.12%
67.89%
78.52% (78.35%)
Quality of Dialysis Center Care and Operations
54.16 (53.87%)
62.47%
72.11%
Providing Information to Patients
74.09%
80.48%
87.14%
Overall Rating of Nephrologists
49.33% (47.92%)
62.22% (60.59%) 
76.57% (75.16%)
Overall Rating of Dialysis Center Staff
49.12% (48.59%)
63.04% (62.99%)
77.49%
Overall Rating of the Dialysis Facility
53.98% (53.46%)
68.59%
83.03%

*If the PY 2022 final numerical value is worse than the PY 2021 finalized value, we will substitute the PY 2022 final numerical value for the PY 2021 finalized value. We have provided the PY 2021 finalized value as a reference in parentheses for clinical measures whose PY 2022 estimated value is worse than the PY 2021 finalized value.

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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