ESRD N ETWORK 6:
QAPI D EVELOPMENT FOR
D IALYSIS P ROVIDERS
Leighann Sauls RN, CDN
Director, Quality Improvement
Do You Recognize this?
T HINK WARM H APPY
T HOUGHTS !
FACT
OR
F ICTION
 The Network collects
endless information from
the dialysis facility for no
good reason
L ET ’ S E XPLORE THE R OLE
OF THE N ETWORK

ESRD Network 6

Incorporated Name –
Southeastern Kidney Council

1 of 18 Networks in the Country

Legislation that Networks exist
W HAT W E D O Network 6 – CMS Contractors
 Clinical Performance Measures
 Anemia
 Adequacy
 Immunization
 Access
 Nutrition
 Complaints and Grievances
 ESRD data forms
 Patient and Provider Education
W HAT DOES THAT MEAN FOR
THE FACILITY ?

Participation in

Quality Improvement Projects

Complaints and Grievances

Data Collection

ESRD Forms
C URRENT Q UALITY
I MPROVEMENT I NITIATIVES

Focus On

Increasing AV Fistulas in South Carolina

Increasing AVF in Network 6 overall

Anemia Management

Adequacy

Increasing Immunizations

Decreasing Complaints and Grievances

Decreasing Involuntary Discharges
D EVELOPING A Q UALITY
A SSESSMENT P ERFORMANCE
I MPROVEMENT (QAPI)
P ROGRAM
V626 C ONDITION STATEMENT

The dialysis facility must develop,
implement, maintain and evaluate
an effective, data driven, quality
assessment and performance
improvement program with
participation by the professional
members of the interdisciplinary
team.
V627 C ONDITION STATEMENT

Effective QAPI

(V627) …an ongoing program
that achieves :
 Measurable improvement in
health outcomes

Reduction of medical errors
V627 C ONDITION STATEMENT

The dialysis facility must
maintain and demonstrate
evidence of its quality
improvement and
performance improvement
program for review by CMS
V638 M ONITORING
I MPROVEMENT
The facility must:

Continuously monitor its
performance

Take actions that result in
performance

improvement

Track to assure improvements are
sustained over time
W HAT
IS
QAPI?

Quality Assessment Performance
Improvement (QAPI)

Under QAPI, the focus is on assessing
outcomes to see whether good results
are being achieved.

More proactive approach to quality and
to improvement.
D IFFERENCE BETWEEN QI
QAPI?
AND

Quality Improvement focuses on
structure and process

Quality Assessment Performance
Improvement focuses on assessing
outcomes
QAPI E LEMENTS

The professional members of the
facility’s interdisciplinary team (IDT),
which must participate in QAPI
activities, consist of a physician,
registered nurse, masters-prepared
social worker, and registered
dietitian.
QAPI E LEMENTS

There must be an operationalized, written
plan describing the QAPI program scope
including:

Objectives

Organization

Responsibilities of all participants

Procedures for overseeing the
effectiveness of monitoring, assessing,
and problem-solving activities.
QAPI E LEMENTS

Within the facilities QAPI program,
facilities are expected to use the
community-accepted standards and
values associated with clinical
outcomes as referenced on the MAT
(measures assessment tool).
QAPI E LEMENTS

If a facility has areas of that do
not meet target levels (per MAT)
or areas where the facility
performance is below average
(per data reports), the facility is
expected to take action toward
improving those outcomes.
QAPI E LEMENTS

QAPI requires the use of aggregate
patient data to evaluate the facility
patient outcomes.

Hemodialysis and peritoneal dialysis
patients should be reviewed separately
since factors affecting their clinical
outcomes may be different; both groups
of patients must be reviewed on an
ongoing basis.
QAPI E LEMENTS

Data related to patient outcomes,
complaints, medical injuries, and
medical errors (clinical variances,
occurrences and adverse events)
should be used to identify potential
problems and to identify
opportunities for improving care.
QAPI P ERFORMANCE M EASURES
INCLUDE :
(V629) Adequacy
Kt/V, URR
(V630) Nutrition
Albumin, body weight
(V631) Bone disease
PTH, Ca+, Phos
(V632) Anemia
Hgb, Ferritin
(V633)Vascular access
Fistula, catheter rate
(V634) Medical errors
Frequency of specific errors
V635) Reuse
Adverse outcomes
(V636) Pt satisfaction
Survey scores
(V637) Infection control
Infections, vaccination status
AVAILABLE D ATA E LEMENTS

CMS Dialysis Facility Reports (DFR)

Facility Specific Data Outcomes
Report

Facility Produced Data

Clinical Variance Reports

Trending Reports from various
facility systems
H OW

Identify the problem

Review collective patient data;


TO DO IT …
Look at trends

Steady improvement or stable outcomes

Abrupt or steady decline in outcomes
Identify any commonalities among patients who
do not reach the minimum expected targets;
One vehicle accident may
not indicate you are a bad
driver…..
However…10 accidents a year may
cause your insurance company to make
some changes in your plan!
N OW W HAT ?

Develop Plan that results in improvement of
care
•
Identify Opportunity for Improvement
•
Set Specific goal for Improvement
•
Define and Measure Root Causes – PRIORITIZE!
•
Identify Interventions
•
Identify Person(s) responsible
•
Date Process began
•
Date/Frequency of Re-measurement
•
Outcomes-Measurement results
T HEN
WHAT ?

Work together – entire IDT

Write clear statement identifying problem

Use numerical “measurable” goal

Set specific time range to meet goal

Assure goal is obtainable within specified time
range

Use smaller goals in step by step fashion until
ultimate goal is reached
Example: GOAL:
Reduce number of catheter patients to <10% by December 2010
Or …
Reduce number of catheter patients by 2% each month
A ND
MORE

Identify Root Causes:

For Example: If a data report shows that the
facility’s ranking for hemodialysis adequacy is
below the expected average

Facility must demonstrate QAPI review of
global factors that might affect adequacy

Brainstorming with IDT

Data/Spreadsheets to “measure” barriers
D EVELOP A CTION AND
I NTERVENTIONS

Focus on process

What process can you change or create that will
have a positive impact?

Make actions barrier-specific

How will changes impact the root cause?

Choose one or two actions which will have the
greatest impact (Rapid cycle improvement)

Review available best practices


Will they work in your facility?
Discuss how you will monitor new processes

How will you know if changes are an improvement?
C HANGE P ROCESSES
Example:

Facility determines inadequate BFR’s are highest priority
root cause for patients not achieving adequacy

Facility reviews current process and determines new
process is needed
NEW PROCESS >

Daily audit checksheet:

Nurse rounds after initiation of each shift to assure BFR
and other prescription parameters are met

Allows action to be taken immediately rather than waiting
for monthly lab review to reveal a problem
E VALUATE

Graph monthly data

Review trends for improvement

Discuss and document changes in
monthly QAPI meetings

What’s working?

What’s not working?
PDCA
F OOD

FOR THOUGHT
Data reported is only as good as
the data entered in the electronic
or hard copy collection tools.
This takes participation and
cooperation of all staff.
Q UALITY IS NOT O NE S IZE F ITS
A LL – INDIVIDUALIZE !
W HERE DO YOU GET DATA FOR
YOUR QAPI?
C OMMENTS , Q UESTIONS , I DEAS –
EMAIL THEM TO
INFO @ NW 6. ESRD . NET
Remember – We are Here to Help You!