ESRD NETWORK 6 2011 ANNUAL REPORT

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CMS GOAL 3 ......................................................................................................................................................................................... 66Patient Web Pages – www.esrdnetwork6.org and www.MYSKC.org .................................................................................................. 67DISASTER PREPAREDNESS ACTIVITIES ................................................................................................................................................................. 67RESOLVING COMPLAINTS AND GRIEVANCES ........................................................................................................................................................ 68Technical Assistance ............................................................................................................................................................................. 71Trend Analyses ..................................................................................................................................................................................... 72IMPACT OF THE SOUTHEASTERN KIDNEY COUNCIL’S GOAL 3 ACCOMPLISHMENTS ...................................................................................................... 74CMS GOAL 4 ......................................................................................................................................................................................... 75OVERVIEW ................................................................................................................................................................................................... 76DIALYSIS AND TRANSPLANT FACILITIES ............................................................................................................................................................... 77RENAL ORGANIZATIONS .................................................................................................................................................................................. 78STATE SURVEY AGENCIES ................................................................................................................................................................................ 79KIDNEY COMMUNITY EMERGENCY RESPONSE COALITION ...................................................................................................................................... 79OTHER COLLABORATIONS ................................................................................................................................................................................ 80IMPACT OF THE SOUTHEASTERN KIDNEY COUNCIL’S GOAL 4 ACCOMPLISHMENTS ...................................................................................................... 81CMS GOAL 5 ......................................................................................................................................................................................... 82OVERVIEW ................................................................................................................................................................................................... 83Data Collection ..................................................................................................................................................................................... 83Data Validation .................................................................................................................................................................................... 85Data Compliance .................................................................................................................................................................................. 85TECHNICAL ASSISTANCE .................................................................................................................................................................................. 87VISION and QualityNet Electronic Data Submission ............................................................................................................................. 87Maintenance and Security of CMS Environment .................................................................................................................................. 87CROWNWeb ......................................................................................................................................................................................... 88IMPACT OF THE SOUTHEASTERN KIDNEY COUNCIL’S GOAL 5 ACCOMPLISHMENTS ...................................................................................................... 89SANCTION RECOMMENDATIONS .......................................................................................................................................................... 90SOUTHEASTERN KIDNEY COUNCIL SANCTION PROCESS .......................................................................................................................................... 912011 SOUTHEASTERN KIDNEY COUNCIL SANCTIONS ............................................................................................................................................ 99RECOMMENDATIONS FOR ADDITIONAL FACILITIES ......................................................................................................... 100DATA TABLES ...................................................................................................................................................................................... 102P a g e | 6
Contents of Figures and TablesFIGURE 1: GEOGRAPHICAL MAP OF THE ESRD RENAL DISEASE NETWORKS .......................................................................................... 11FIGURE 2. PREVALENT ESRD PATIENTS PER NETWORK AS OF 12/31/2011. .......................................................................................... 12FIGURE 3. NUMBER OF ESRD FACILITIES PER NETWORK AS OF 12/31/2011. ........................................................................................ 13TABLE 1. US CENSUS QUICK FACTS DATA ON RACIAL AND ETHNIC COMPOSITION OF THE US COMPARED TO NETWORK 6 ................. 14FIGURE 4. US CENSUS AND NETWORK RACIAL DISTRIBUTION COMPARISON ....................................................................................... 14TABLE 2. NETWORK 6 ESRD PREVALENCE AND INCIDENCE AS OF 12/31/2011...................................................................................... 15FIGURE 5. NETWORK 6 PATIENT POPULATION 5-YEAR GROWTH .......................................................................................................... 15TABLE 3. DEMOGRAPHICS OF NETWORK 6 INCIDENT ESRD PATIENTS .................................................................................................. 16FIGURE 6. NUMBER OF NEW ESRD PATIENTS BY AGE GROUP CALENDAR YEAR 2011 ........................................................................... 16FIGURE 7. NUMBER OF NEW ESRD PATIENTS BY RACE CALENDAR YEAR 2011 ...................................................................................... 16FIGURE 8. NUMBER OF NEW ESRD PATIENTS BY PRIMARY DIAGNOSIS CALENDAR YEAR 2011 ............................................................. 16FIGURE 9. NETWORK 6 NUMBER OF FACILITIES BY YEAR ...................................................................................................................... 17FIGURE 10. NETWORK 6 PERCENT OF FACILITIES BY OWNERSHIP ......................................................................................................... 17FIGURE 11. NETWORK 6 AV FISTULA RATE INTERVENTION PROGRESSION CHART ................................................................................ 34FIGURE 12. NETWORK 6 2011 NUMBER OF AV FISTULAS IN USE BY MONTH ........................................................................................ 35FIGURE 13. NETWORK 6 2011 NUMBER OF AV FISTULAS PLACED BY MONTH ...................................................................................... 35FIGURE 14. PERCENT OF NETWORK 6 FACILITIES THAT HAVE REACHED CMS AVF RATE OF 66% OR MORE BY MONTH ........................ 36FIGURE 15. AV FISTULA INTERVENTION FACILITY SELECTION FLOW CHART .......................................................................................... 37FIGURE 16. REPORT 101- ESRD NETWORK 6 VASCULAR ACCESS FEEDBACK REPORT. ........................................................................... 38FIGURE 17. REPORT 102- VASCULAR ACCESS RANKING REPORT ........................................................................................................... 39FIGURE 18. REPORTS 105 AND 105B ..................................................................................................................................................... 39FIGURE 19. NETWORK 6 2011 CATHETER USE DISTRIBUTION BY MONTH ............................................................................................. 41FIGURE 20. NETWORK 6 2011 LONG-TERM (>90 DAYS) CATHETER USE DISTRIBUTION BY MONTH ...................................................... 42FIGURE 21. DISTRIBUTION OF LONG-TERM CATHETER USE DURING THE 2011 FOCUSED INTERVENTION ............................................. 42FIGURE 22. CATHETER USE REDUCTION FACILITY-SPECIFIC FEEDBACK REPORT .................................................................................... 43FIGURE 24. DISTRIBUTION OF THE % OF NETWORK 6 PATIENTS WITH URR> 65 ................................................................................... 45FIGURE 23. PROGRESSION OF NETWORK 6 ADEQUACY FOCUS FACILITIES............................................................................................ 45FIGURE 25. DISTRIBUTION OF NETWORK 6 URR RATES BY FACILITY ..................................................................................................... 46FIGURE 26. HEMODIALYSIS ADEQUACY PROGRESSION REPORT ........................................................................................................... 47FIGURE 27. NETWORK 6 IMMUNIZATION RATES (2009-2012) .............................................................................................................. 48P a g e | 7
Page 1 and 2: “IMPROVING THE LIVES OF PEOPLE WI
Page 3 and 4: STATEMENT FROM THE BOARD OF DIRECTO
Page 5: Table of ContentsPREFACE ..........
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 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
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Impact of the Southeastern Kidney C
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Medical Review Board and Board of D
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Patient Ambassador Pilot ProgramIn
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ole of Network 6, Dialysis Facility
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OverviewIn 2011, Southeastern Kidne
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CMS requires that Networks assume a
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Number of ContactsTechnical Assista
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Number of CallsNumber of CallsThe o
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CMS Goal 4Improve collaboration wit
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A collaborative project is a system
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State Survey AgenciesSoutheastern K
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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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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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