ESRD NETWORK 6 2011 ANNUAL REPORT

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Percent20.0%18.0%16.0%14.0%12.0%10.0%8.0%6.0%4.0%2.0%0.0%Percent of Network 6 facilities meeting or exceeding CMS 66%AVF rate goalJan Feb Mar Apr May June July Aug Sept Oct Nov Dec% OF Facilities 12.1% 12.9% 13.2% 13.8% 13.8% 14.0% 14.8% 16.5% 17.2% 17.6% 17.7% 18.8%MonthFigure 14. Percent of Network 6 Facilities that have reached CMS AVF rate of 66% or more by monthVascular Access Intervention OverviewFacility Selection:All Network 6 facilities were included on the vascular access intervention. The MRBdivided facilities into intensive and intermediate intervention groups.Intensive Intervention: (N=176 dialysis facilities total for Vascular Access / N=111 for thisQIP, the remaining 65 in the intensive intervention facilities for the Catheter Reduction QIP)The MRB selected facilities with a prevalent AV FISTULA rate below 66% in March 2011and operated by a corporate group of at least 20, based on the following criteria:At least 15 incident patients in 2010 (N=102)A prevalent long-term catheter rate greater than 10% in March 2011 (N=65) – thesefacilities were be the focus of the 1d project (outlined in green in the figure below)At least 10 AV fistulas in place in prevalent patients in March 2011 that were notbeing used (N=9)Intermediate Intervention: All remaining Network 6 facilities not selected for theintensive arm of the intervention were included in the intermediate intervention arm. (N=384)P a g e | 36
Figure 15. AV Fistula Intervention Facility Selection Flow ChartIntervention Implementation:Step 1- Notified LDO Chief Medical Officers (CMO) of the Intervention andExpectationsStep 2- Notified LDO Regional and Divisional Vice-Presidents (RVP/DVP) of projectoverview and Network 6 expectations of their leadership role in the projectStep 3- Notified facilities of intervention expectations via meetings with the MedicalDirector and Clinic ManagerFacility expectations for the intervention:Monthly self-report data collectionMonthly root cause analysisMonthly updates to action plansEducation learning session with required visual component via bulletinboard for beneficiaries and staffStep 4- Notified State Surveyors of project goals, interventions and desired outcomesStep 5- Provided feedback, technical assistance and education to all facilitiesP a g e | 37
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 and 30: CMS NATIONAL GOALS & NETWORK ACTIVI
Page 31 and 32: The Quality of Care Commitment stat
Page 33 and 34: Network 6 Quality Improvement Progr
Page 35: Number of AVFsNumber of AVF in Use2
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
Page 83 and 84: OverviewSoutheastern Kidney Council
Page 85 and 86: 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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