ESRD NETWORK 6 2011 ANNUAL REPORT

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STRATEGY TO ACCOMPLISH CMS GOALSThe Board of Directors recognizes the need for a strong partnership of patients, providers,regulators and allied health organizations to accomplish CMS goals. The Board and its Committeesbelieve a collegial, collaborative, and continuous quality improvement environment is most effectivefor achieving the goals. When this approach does not provide expected outcomes, the Networkcontract includes the ability for the Network to recommend a non-performer to CMS for sanction oralternative sanction (see Sanction section later in this report.).The dialysis and transplant facilities in the Network 6 area, with the Consumer members of theBoard of Directors form the Network Coordinating Council. As members of the Council, each facilitysigns a Quality of Care Commitment Statement with the Southeastern Kidney Council, joining inmembership with other approved ESRD facilities in Network 6 to ensure patients receive safe,effective, high quality care. Each facility agrees to participate in the activities of the SoutheasternKidney Council and to support Network goals. Facilities acknowledge that compliance with thesegoals is a condition for approval to receive Medicare reimbursement for the provision of ESRDservices. (42 CFR §494.180 Condition: Governance)The Quality of Care Commitment states that all facilities will:Provide the highest quality of care to every patient we treat by staying abreast of currentscience, seeking and using Best Practices, and striving to meet Network Quality Goals usinga data-driven quality assessment and performance improvement plan.Advocate for the patient to ensure every patient receives the right care, every time.Cooperate with the Network, participate in Network activities, and pursue Network goals tofulfill the terms of the current Network Statement of Work.Identify a governing body that receives and acts upon Network recommendations.Provide timely and accurate data and information to support the national ESRD registry, tofacilitate measurement and improvement of care and to resolve patient complaints.Cooperate with the Network Medical Review Board (MRB) on all QI activities including QIProjects and Focused Review, including submission of information and responding to MRBrecommendations.Cooperate with the Network in prevention and resolution of patient concerns, complaintsand grievances. This includes educating patients on the Network’s role in complaint andgrievance resolution, posting the Network address and phone number and notifying theNetwork at least 30 days prior to involuntarily discharging a patient.Share educational information with patients as requested by the Network and helps educatepatients on the role and services of the Network.Follow all CMS/HIPAA rules for secure transmission of data.P a g e | 30
The Quality of Care Commitment states that the Southeastern Kidney Council agrees to:Provide educational resources and technical assistance to facilities and patients to helpimprove the quality of care.Provide comparative feedback reports that facilities can incorporate into local QI projects.Provide education, tools and technical assistance to assist patients and facilities to:o Prevent and resolve conflict between patients and providerso Improve the quality of careo Ensure data submission is accurate and timelyOversee all Network activities through the multidisciplinary Board of Directors and itscommittees to ensure projects are effective, reasonable and appropriate for patients andproviders in the Network 6 area and that SKC conducts activities in an environment freefrom conflict of interest and with a cultural awareness and sensitivity.ESRD NETWORK 6 INTERNAL PROCESS MEASURESUsing the same Quality Improvement Principles employed with facilities to improve care, Network 6conducts Internal Quality Improvement (IQI) to monitor processes related to delivery of the contract.The Network 6 IQI plan, prepared and submitted to CMS for approval, includes these components:IQI Indicators – Defines each Indicator and provides the numerator and denominator, thedata source for calculating it, the frequency on which it is calculated and which staff memberwill champion the Indicator.IQI Radar Screen – Created monthly, based on the Indicator definitions, SKC uses theRadar Screen to review all Network 6 Indicators, as any Indicator crossing trigger point willautomatically light up red for further study.RCA Template – Guides staff through the RCA steps and documents all actions. Thisfollows Network 6’s 7-step PDCA methodology.Plan:Describe the problemDescribe the current processIdentify root causesDevelop a solution and action planDo: Implement the solutionCheck: Review and evaluate resultsAct: Reflect and act on learningsProject Management Software tracking and review – each week, staff meets to review thework plan, identify barriers and celebrate successes.APPDCAMethodsCDP a g e | 31
Page 1 and 2: “IMPROVING THE LIVES OF PEOPLE WI
Page 3 and 4: STATEMENT FROM THE BOARD OF DIRECTO
Page 5 and 6: Table of ContentsPREFACE ..........
Page 7 and 8: Contents of Figures and TablesFIGUR
Page 9 and 10: DATA TABLES LISTINGDATA TABLE 1: NE
Page 11 and 12: Network DescriptionESRD Network Pro
Page 13 and 14: Number of FacilitiesGENERAL POPULAT
Page 15 and 16: Number of PatientsGENERAL POPULATIO
Page 17 and 18: GENERAL POPULATIONESRD FacilitiesAt
Page 19 and 20: CORE VALUESIn achieving our Mission
Page 21 and 22: Quality ImprovementLeighann Sauls R
Page 23 and 24: Board of DirectorsThe Board of Dire
Page 25 and 26: Finance CommitteeIn 2011, the Board
Page 27 and 28: Medical Review BoardThe Medical Rev
Page 29: CMS NATIONAL GOALS & NETWORK ACTIVI
Page 33 and 34: Network 6 Quality Improvement Progr
Page 35 and 36: Number of AVFsNumber of AVF in Use2
Page 37 and 38: Figure 15. AV Fistula Intervention
Page 39 and 40: Report 102 - VascularAccess Ranking
Page 41 and 42: Number of CathtersPROJECT 2: INCREA
Page 43 and 44: Intervention ImplementationSKC empl
Page 45 and 46: Figure 23. Progression of Network 6
Page 47 and 48: Feedback Reports to each focus faci
Page 49 and 50: Immunization Intervention overviewF
Page 51 and 52: Impact of the Southeastern Kidney C
Page 53 and 54: OverviewThe Network meets the expec
Page 55 and 56: Mental Healtho Living and Loving Li
Page 59 and 60: Medical Review Board and Board of D
Page 61 and 62: Patient Ambassador Pilot ProgramIn
Page 63 and 64: ole of Network 6, Dialysis Facility
Page 67 and 68: OverviewIn 2011, Southeastern Kidne
Page 69 and 70: CMS requires that Networks assume a
Page 71 and 72: Number of ContactsTechnical Assista
Page 73 and 74: Number of CallsNumber of CallsThe o
Page 75 and 76: CMS Goal 4Improve collaboration wit
Page 77 and 78: A collaborative project is a system
Page 79 and 80: State Survey AgenciesSoutheastern K
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Impact of the Southeastern Kidney C
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OverviewSoutheastern Kidney Council
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Data ValidationSoutheastern Kidney
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Technical AssistanceThe Southeaster
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Impact of the Southeastern Kidney C
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Background and OverviewSoutheastern
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§ 488.606 Alternative sanctions.(a
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Congress extended Medicarecoverage
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Return to routine monitoringHas fac
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2011 Southeastern Kidney Council Sa
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RecommendationsPeople with end stag
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DATA TABLE 1: NETWORK 6 ESRD INCIDE
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DATA TABLE 2: NETWORK 6 ESRD PREVAL
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DATA TABLE 3: NETWORK 6 HOME DIALYS
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DATA TABLE 3: Network 6 HOME DIALYS
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DATA TABLE 4: NETWORK 6 IN-CENTER D
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DATA TABLE 5: NETWORK 6 NUMBER OF R
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DATA TABLE 6: Network 6 NUMBER OF R
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DATA TABLE 7 Network 6 DIALYSIS DEA
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DATA TABLE 8: NETWORK 6 VOCATIONAL
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ESRD NETWORK 6 2011 ANNUAL REPORT

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