ESRD NETWORK 6 2011 ANNUAL REPORT

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% URR >65%Adequacy Focused Review Intervention OverviewFacility Selection:Thirty of the poorest performing facilities were selected for the “Adequacy Focused Review”based on not meeting the set goal of 90% of patients dialyzing with a URR of >65%. Focusfacilities were the facilities with > 40 patients and less than 80% of the patients with a URR >65%. The Network 6 Medical Review Board utilized the <strong>2011</strong> Lab Data Collection gathered inQuarter 4 of 2010, to identify the focus facilities based on designated cut points. The MRBexcluded pediatric facilities and those facilities with less than 40 patients.1101009080706050403020100Facilities Chosen ->40 patients and65% -N=30Facilities below theNational Average of91.1% (N=157)Adequacy - Distribution of URRData Source: ELab Q4 2010Network 6 FacilitiesFigure 25. Distribution of Network 6 URR rates by facilityIntervention Implementation:Step 1- Notified facilities’ Medical Directors, Regional Management, Clinical Manager and StateSurveyors of inclusion into projectStep 2- Notified facilities of the intervention and sent project information. SKCinformed facilities of their reporting requirements: Monthly Lab Data Collectionwith required elements, first action plan with Root cause analysis and quarterlyRoot Causes with interventions and process changes based on previous monthsdataStep 3- Provided feedback, technical assistance and education to all facilitiesP a g e | 46
Feedback Reports to each focus facilityNetwork reviewed information and sent feedback reports monthly (sample below)Figure 26. Hemodialysis Adequacy Progression ReportSKC provided technical assistance to focus facilities via the following:Network 6 sponsored Webinarso November Webinar: Project outline and Adequacy Management• Goals, Activities, Timelines• CQI process for development of action plan• Fundamentals of problem statement with root cause analysiso December Webinar: Action Plans• Adequacy Root Causes• Best Practices• Proven interventionso Webinar 3: Identifying and addressing Root CausesNetwork QI Nurse collected and reviewed facility Adequacy Action Plans,providing written technical assistance to each facility. Six facilities were requiredto resubmit plans based on this review.Learning Session Summary Sheets were reviewed and approved by the NetworkQI NurseP a g e | 47
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 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: Figure 23. Progression of Network 6
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
Page 87 and 88: Technical AssistanceThe Southeaster
Page 91 and 92: Background and OverviewSoutheastern
Page 93 and 94: § 488.606 Alternative sanctions.(a
Page 95 and 96: Congress extended Medicarecoverage
Page 97 and 98:
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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