Increasing AVF Rates in Facilities with AVF Rates < 50%

Reduction in Long-Term Catheter Rate ProjectLisle Mukai, QI CoordinatorESRD Network 18October 1, 2009

1Special Acknowledgement for Slide Content Contribution:Fistula First Breakthrough Initiative WebsiteMid-Atlantic Renal Coalition (FFBI: Presentation to CMS/ESRD-Annual Meeting)CMS Surveyor Training (Condition: Quality Assessment and Performance Improvement - Show Me The Progress

2Fistula First Breakthrough Initiative (FFBI)The FFBI is a collaboration between the Centers for Medicare and Medicaid Services (CMS), ESRD Networks, and the renal community. Began in 2003Main objective: To have every eligible patient receive the most optimal form of vascular access-AVFTo ensure every vascular access undergo appropriate monitoring and surveillance to avoid vascular access complications.

3Fistula First AVF GoalsCMS Prevalent AVF Goal = 66%

Network 18 2009-2010 AVF Goal:Network 18 Goal = 57.8%Network 18 Stretch Goal = 58%

Current AVF Rates:National: 53.2% (July 2009)Network 18: 56.9% (July 2009)

Although the majority of facilities and the Network in general is progressing towards CMSs goal, we still have a several facilities that do not meet at least the minimum 50% AVF rate.

4CMS & Network 18 Goals for Long-Term CathetersCMS & Network 18 Long-Term Catheter (LTC) [> 90 Days] Goal = < 10%

Current LTC Rate:National: 21% (2008 CPM)Network 18: 7.9% (July 2009 SIMS data)Just like the AV fistula rates, although majority of the facilities and the Network in general are achieving this goal, there are several facilities that are not.

Ultimately the goal for all Network Fistula First projects is to increase AV fistula rates. So it goes to say that if you decrease your long-term catheter rate, your AV fistula rate should then increase.5Tools & Best Practices:Fistula First Change ConceptsRoutine CQI Review of vascular accessTimely referral to nephrologistEarly referral to surgeon for AVF OnlySurgeon SelectionFull range of appropriate surgical approaches

Secondary AVFs in AVG patientsAVF evaluation/ placement in catheter ptsCannulation trainingMonitoring and maintenanceContinuing EducationOutcomes feedback

Since majority of our facilities have basically reached a plateau in their AVF rates because all patients that are eligible for AVFs have them placed, within the last year or so, we have been encouraging facilities to concentrate on Change Concepts 6, 7, and 9 to further improve facility vascular access outcomes.

During this project, we will focus on Change Concept #7.

These elements should be considered as it applies to your facility.

For example, if your facility has a > 10% long term catheter rate, then your facility should consider concentrating on Change Concept #7 as one of its focus.

Or

If your patients do not conduct routine stenosis monitoring and surveillance on AVFs or AVGs or assess maturity of newly placed AV fisutlas, then you must implement Change Concept #9.6Cost Per Patient by Access Type(USRDS 2006 data)Annual Per Patient Per Year ExpenditureCatheter $77,093Graft $71,616AVF $59,470

The annual per patient cost savings of an AVF over a graft is $12,269

The annual per patient cost savings of an AVF over a catheter is $17,746

7Network 18 activities to promote & support Fistula FirstMonthly data collection Electronically by LDOs (DaVita & FMC)Manual submission by Independent & SDOs.

Distribute quarterly feedback reports (Facility-specific reports, SIMS reports, and Network summary reports)

Sharing best practices via Fistula First Newsletter

8Network 18 activities to promote & support Fistula First (continued)Provide current educational information relevant to professionals and patients on the NW 18 website and mailings.

Work with the MRB to develop projects to assist identified facilities in improving outcomes.

Site visits9Reduction in Long-Term Catheter Rate ProjectFacilities > 50% AVF Rate = 73.1%(198 facilities as of May 2009)108 facilities = 50-59%67 facilities = 60-69%23 facilities = > 70%

Facilities < 50% AVF Rate = 26.9%(73 facilities as of May 2009)The MRB decided to conduct this project with your facilities because your facilities are currently below 50% AVF rate and are not meeting the CMS/Network goal of < 10% long-term catheter rate.

As of May 2009, there is a total of 271 Fistula First facilities in Network 18.

10Reduction in Long-Term Catheter Rate Project (continued)Facilities < 10% LTC Rate = 70.5%(191 Facilities as of May 2009)Facilities > 10% LTC Rate = 29.5%(80 Facilities as of May 2009)64 facilities = 10-19%12 facilities = 20-29 %3 facilities = 30-39%1 facility = > 40%

11Facilities in this < 50% category need to find more creative ways of improving their vascular access outcomes. We have found that most of these facilities have either high long-term catheter rates or high AV graft rates.

12Reduction in Long-Term Catheter Rate Project (continued)Inclusion Criteria for the project: LTC rate > 10% (May 2009 SIMS data) AVF rate < 50% (May 2009 SIMS data) Patient census > 50 patients

Exclusion Criteria: Patient census < 50 patients Facilities already included in another QIWP Project (exception of SMR and Clinical Indicator Goals Project) Facilities participating in Phase 2 of CROWNWeb13Reduction in Long-Term Catheter Rate Project (continued)Objective: To have each participating facility review their vascular access program and determine root cause(s) for their facilitys increased LTC rate. Each facility will develop a Quality Assessment and Performance Improvement Plan to improve their LTC rate based on their root cause analysis Implement their plan and improve their plan along the way by making necessary changes if certain strategies/activities are not successful.Develop a process to sustain improvements.

14Reduction in Long-Term Catheter Rate Project (continued)Goal:Group Goal: To reduce the LTC rate within the group of intervention facilities from 16.6% to 15.6% by June 2010.Facility Goal: To reduce the facilitys LTC rate by at least 6% by June 2010.

Timeline:Project period: September 2009 to June 2010

The goal of the project is for the group of intervention facilities to reduce the LTC rate from 16.6% to 15.6% by June 2010. To achieve this goal each facility would then need to reduce their LTC rate by at least 6% during the project.

We will provide you your facilitys goal when we distribute the project toolkit next week.

The baseline LTC rate we will use for the project is the SIMS Vascular Access Rate for May 2009.

15Reduction in Long-Term Catheter Rate Project (continued)Due dates:Facility Manager Acknowledgement Letter August 27, 2009Environmental Scan August 27, 2009Medical Director Acknowledgement Letter September 10, 2009Quality Assessment and Performance Improvement Plan (PDSA: Plan-Do-Study-Act format) November 4, 2009For the Medical Director Acknowledgement Letters, if you received a delinquent notice that we have not received this letter please remind your Medical Directors to sign and send that in to us. These letters were addressed and mailed to the Medical Director. 16Reduction in Long-Term Catheter Rate Project (continued)Conference CallsMonthly calls to share and discuss successes and issues.Very important because it gives each facility the chance to discuss their concerns or share their issues with others and possibly find solutions to problems.

The 1st Wednesdays of the month starting on November 4, 2009 at 2pm.Conference calls for this project will be held monthly.

Conference call meetings will be scheduled for the 1st Wednesdays of the month to discuss issues, concerns, ask questions, etc. These meetings will be held for open discussions and brainstorming that may be beneficial for all facilities.

This will also allow you to evaluate your plans at least monthly and revise them as necessary with possible solutions or ideas from other facilities.

Have a representative present at each call.17Reduction in Long-Term Catheter Rate Project (continued)Network Responsibilities:Project Leader Instruct/assist with the QI processDistribute templates for RCA and PDSADistribute toolkits/resources and evaluate their usefulness

18Reduction in Long-Term Catheter Rate Project (continued)Network Responsibilities (continued)Provide monthly feedback reports (SIMS)Facilitate monthly conference callsProvide technical assistance as necessaryConduct facility site visits as necessary

19Reduction in Long-Term Catheter Rate Project (continued)Facility Responsibility:Conduct a root-cause analysis and develop a Quality Assessment and Performance Improvement (QAPI) PlanSubmit your QAPI planImplement QAPI plan and revise as necessary during the projectMonitor your facilitys progress towards achieving the goal

To conduct a root-cause analysis and develop a Quality Assessment and Performance Improvement Plan with their interdisciplinary team.A copy of the QAPI plan will be submitted to the NWTracking and trending your improvements20Reduction in Long-Term Catheter Rate Project (continued)Facility Responsibility (continued):Identify tools that would be useful for your facilityParticipate in monthly conference callsFollow project timelines/due datesSubmitting requested documents for the project in a timely manner

21Quality Assessment and Performance Improvement Plan (QAPI)494.110: (V626) Condition

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.This is a condition level requirement.

Interpretation of this requirement can be found under v-tag V626 in the Interpretive Guidelines. The Interpretive Guidelines along with the new Conditions for Coverage can be found on the Network 18 website. 22Quality Assessment and Performance Improvement Plan (QAPI)Interdisciplinary Team: (minimum) Physician Registered nurse Social Worker Dietitian

Also include your surgeon(s) and interventional radiologist(s)

Considering this project is focusing on vascular access, it would be a great idea to include a surgeon and even an interventional radiologist on this team since they play a big role in vascular access care.

Also included is the Vascular Access Coordinator.23Quality Assessment and Performance Improvement Plan (QAPI) (continued)Standard: Program Scope:

1. The program must include, but not limited to, an ongoing program that achieves measurable improvement in healthcare outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.During this project we will be focusing on vascular access outcomes - specifically catheter and AV fistula outcomes.

Vascular outcomes are the data-driven indicators and measures we will be looking at during this project.24Quality Assessment and Performance Improvement Plan (QAPI) (continued)Standard: Program Scope:

2. The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations.Per the Interpretive Guidelines: Facility data should be analyzed by the interdisciplinary team on an ongoing basis. The facility must use broadly accepted, community-developed standards as performance measures (this could be the MAT tool and CMS/NW goals) The interdisciplinary team must work with inidvidual pateints who do not reach the targets and it must be reflected in the patients plan of care for that outcome.

The facility should also track and trend data for improvement and sustainability of those improvements.25Quality Assessment and Performance Improvement Plan (QAPI) (continued)Standard: Monitoring performance improvement:

The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.Per the Interpretive Guidelines: Tracking and trending, analysis of root causes, development of improvement plans, implementation of those plans, evaluation of the success of the plan, and revision of the plan must occur as indicated which is basically re-measurement of your data for improvements and review of your QAPI plan.

Once improvement is made, the facility must have a mechanism to ensure that improvements are sustained. This could be tracking and trending and having triggers to know when the facility needs to re-evaluate their plan or process.26Quality Improvement Process

Root Cause Analysis:Finding the real cause of the problem and dealing with it rather than simply dealing with the symptoms. Those situations which are recurring with the greatest frequency and consume the greatest amount of resources to rectify are candidates for RCA To find the root cause, ask Why? until the pattern completes and the cause of the difficulty in the situation becomes rather obvious. Gene Bellinger 200427

One form of root cause analysis is using the fishbone diagram.

The problem is written as the head of the fish skeleton. From there, the spines are all categories and specific causes that could contribute to the problem. And as I said previously, with each specific cause, ask Why it is ocuring until you get to the bottom of the cause in which you cannot ask why anymore. You can add as many spines on your fishbone diagram as needed.28Quality Improvement Process:Plan-Do-Study-Act:PDSA is the format the Network uses for developing a QAPI plan.

ACTPLANSTUDYDOOnce you have determined a root cause. You then can develop your plan using the PDSA (Plan-Do-Study-Act) model.

This model encompasses the elements of a QAPI plan as stated in the CfC requirements.

A continuous process.29Adopted from IHI Website, June 2007PROJECT: TEAM: (List all members)BACKGROUND: (Summary of facilitys identified problem and description of what the facility has been doing to improve the problem.)Step 1.PLAN:Plan the test.What is the objective of this improvement cycle?What is the goal? (Include a numeric goal to achieve.)Develop a plan to achieve the goal? (List steps of the plan this will allow you to identify the step that may need modifying/revising if necessary.)2 of 3 pagesWhat data sources are needed for the test? (What data sources will you be using to monitor your progress?)What measures are used to analyze if you are achieving the goal?Baseline: Measure: (Numerical formula)Monitoring frequency:

PDSA TemplatePDSA template that will be sent to your facility to help in developing the facilitys QAPI plan.

30Step 2.DO:Try out the test on a small scale.Implement the plan. Document problems and unexpected observations.Step 3.STUDY:Set aside time to analyze the data and study the results.Analyze the results and compare the results with your goal.Step 4.ACT:Determine if the test was successful or the plan needs to be revised.If the test was successful, how will you implement the plan on a wider scale?If it was not successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes?31Plan-Do-Study-Act (PDSA)Plan: Set your objective for the project Set goals to achieve (numerical goals and a target date) Develop your plan on how you will improve your identified problem List data sources you will use to monitor your progress for the project

Elements under plan are: Setting your objective for the project What you are hoping to accomplish with this plan.

Setting goals to achieve (determine numerical goals and a target date) For this project the goal for each facility is to reduce their LTC rate by at least 6% by June 2010.

Developing your plan on how you will improve your identified problem Make sure you write the details your plan. List your activities/strategies step-by-step By writing out your plan step-by-step, you can easily go back to the specific activity or strategy that may not have worked and revise it or change it. Please remember that you can only develop a plan for those issues you can control.

List data sources you will use to monitor your progress for the projectExamples of this is your facility-specific SIMS report from the Network, your internal facility vascular access logs, patient tracking logs, etc.

32Plan-Do-Study-Act (PDSA) (continued)Plan (continued): Write out the measure you will be using to analyze if you are achieving your goal. (numerical formula) # of prevalent patients using an LTC as primary access Total # of patients at the facility

Write out the measure you will be using to analyze if you are achieving your goal. This is usually a numerical formula.

33Plan-Do-Study-Act (PDSA) (continued)Plan (continued):

Note your baseline for comparison towards your goal Note the frequency in which you will conduct measurement of your progressFor this project we will be re-measuring monthly.

34Plan-Do-Study-Act (PDSA) (continued)Plan (continued):

In your plan, please include a process to monitor newly placed AV fistulas for maturation.Ensure that the access is access using the Look, LISTEN, and Feel method.Refer the patient for follow-up 4 weeks post placement to ensure the access is maturing properly.35Plan-Do-Study-Act (PDSA) (continued)Plan (continued):

When you develop your plan, write outyour methodology (what you are goingto do step-by-step). This way when youimplement your plan you can go back tothe step that may not have worked andrevise it.

36Plan-Do-Study-Act (PDSA) (continued)Do: Implement your plan Document problems and unexpected observations of your plan

Study: Analyze the results and compare it to the goal This analysis should be conducted with the interdisciplinary team. Revise plan if necessary to achieve goal

Step 2 Do: Implement your plan. Note the problems you encounter and other findings. By noting these you can review your plan and determine what changes can be or needs to be made to your plan.

Step 3 Study: Using your data sources, analyze the results of your plan with your interdisciplinary team. Are you progressing towards your goal? Track and trend your progress. This way it will be easy to visually see if you are moving towards your goal. If you are not progressing towards the goal, revise your plan as necessary to achieve the goal think of new strategies.

37Plan-Do-Study-Act (PDSA) (continued)Act: Is your plan successful? How will you ensure continued improvement?

If it wasnt successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes?

And Step 4 Act:

This step assess if your plan is successful Are you moving towards your goal or have you already achieved your goal.

If you are successful, how will you ensure continued improvement? - The facility can monitor improvements to ensure sustainability, develop a process or policies & procedures, etc.

If it wasnt successful what needs to be changed base on what you have learned. - Should you continue looking for other root causes?

38Plan-Do-Study-Act (PDSA) (continued)The PDSA cycle is a continuous cycle. It allows you to frequently assess your plan and make revisions as necessary to achieve your goal.

Your plan should be reviewed at least monthly and/or when you realize that your strategy or activity is not working.

39Plan-Do-Study-Act (PDSA) (continued)You can go back to any step and revise as necessary.

Note your progress on your form so that you have a record of the strategies/activities youve attempted and results of those attempts as well as the revisions you have made to improve your plan.

40Overcoming Obstacles and BarriersCategories for Network 18 facilities common obstacles and barriers: Education Process CommunicationIn conducting a root cause analysis of Network 18 facilities possible obstacles and barriers based on previous projects and communication with the community, majority of the obstacles we have found can be summarized under 3 categories:

Education Process Communication

41Overcoming Obstacles and Barriers (continued)Insurance: Communication:When you send a patient to the surgeon for de-clotting of an AVG or catheter send a letter to that surgeon explaining all the difficulties and frequency of those difficulties you have had with that access and why you would like that patient evaluated for an AVF. When the problem occurs frequently, it is justifiable for the surgeon to recommend and place another access.

Some examples of possible solutions to these issues as learned from other facilities or suggested by the FFBI.

To learn other possible strategies or solutions for issues is to discuss them with other facilities. At the least, you can brainstorm with these other facilities to find solutions for your issues or common issues together.

42Overcoming Obstacles and Barriers (continued)Fistula First has a Payer Packet (Found on Fistula First website)Includes: Flyer explaining about the Fistula First Breakthrough Initiative, why this program matters, and what the insurance company can do. Summary of Recommendations FFBI Priority Recommendations Graphs/charts on vascular access costs

43Overcoming Obstacles and Barriers (continued)Fistula First Sample Letter for PCP or Insurance companies (Found on the Fistula First website)Encourage patients to become an advocate for their care. Involve SW to assist patient on what to discuss with the insurance company.

This letter is designed for nephrologists to communicate with Primary Care Physicians or Insurance companies regarding early referral for CKD patients.

44Overcoming Obstacles and Barriers (continued)No surgeons/good surgeons in the area:Education:Nephrologists and the facility (Medical Director, Manager or Vascular Access Coordinator) speak with surgeons about the Fistula First program and the facilitys expectation of the surgeon to meet goals of the Fistula First program.Refer surgeons to the Fistula First website for resources including the surgical video Creating AV Fistulae in All Eligible Hemodialysis Patients Most areas have at least one surgeon available to serve the ESRD patient population. Education and communication with these surgeons can possibly make a difference.

Creating AV Fistulae in All Eligible Hemodialysis Patients this was the surgical video that was distributed to all the facilities and vascular surgeons a few years back

When available, inform your surgeons of surgical symposiums or conferences - encourage them to attend.

45Overcoming Obstacles and Barriers (continued)Education (continued):Share the Cannulation DVD with the surgeons so that they understand the logistics of cannulation and can position the veins suitably and safely for cannulation.

Communication:If facilities in the same area use the same surgeon(s), all facilities should communicate the same message/urgency regarding AVF placement.

46Overcoming Obstacles and Barriers (continued)Communication (continued):The San Diego and Orange County areas have Dialysis Access Club meetings in which any surgeons, interventional radiologist, nephrologists, and dialysis staff can attend. These meetings are a great open discussion forum for issues in accesses creation, complications, etc. that these disciplines can discuss.

Nephrologists can discuss with their colleagues about which surgeons they utilize and how well those surgeons perform.

Encourage your surgeons to attend these meetings - have them speak with their colleagues in those counties to find out when these meetings are scheduled.

47Overcoming Obstacles and Barriers (continued)Process:If you have access to a Vascular Access Center, use those facilities for AVF evaluations - vein mapping and communicate results with surgeons. You can also use the centers for follow-up after an AVF placement to ensure the access is maturing.Implement Change Concept #4: Surgeon selection based on best outcomes, willingness, and ability to provide access services.

These centers can also remove catheters.

Under this Change Concept: Nephrologists should communicate expectations to surgeons regarding AVF placement and training in current AVF surgical techniques, based on KDOQI Guidelines and best practices. Nephrologists should refer to surgeons willing and able to meet AVF expectations based on KDOQI and best practices. AndSurgeons should be continuously evaluated on frequency, quality, and patency of access placements. The surgeons outcomes can be tracked at the facility level and should be incorporated in your vascular access program.

48Overcoming Obstacles and Barriers (continued)Process (continued):The facility should develop a tracking system to monitor their surgeons performance. This can be used to:Determine continued referral to that surgeonDevelop a report card for that surgeonDiscuss with the surgeon how to improve performance or technique referral to resources.

The facility should track and monitor their surgeons performance, especially those that you feel may need improvements.

Develop report cards about that surgeons performance. Maybe if the surgeon seesthat his fistula creations are not maturing, not usable, or other issues are associated with them like where he places them are not very accessible or comfortable, he will re-evaluate his techniques.

49Overcoming Obstacles and Barriers (continued)Process (continued):Encourage nephrologists to refer patients for evaluation while the patient is still in the hospital. If unable to do prior to discharge, encourage the nephrologist to schedule an appointment for outpatient evaluation.

50Overcoming Obstacles and Barriers (continued)No communication/relationship between Nephrologist and Surgeon:Communication:Try and convey to these physicians and surgeons that the ultimate concern is the patients well being. Involve Regional Managers and/or Medical Directors to talk with them and convey the facilitys goals and expectations.

It has come to our attention that there are areas in which the nephrologists and surgeons do not have a working relationship much less any communication because of politics or personal differences and issues.

Try to convey to these physicians and surgeons that the ultimate concern is the patients well being. Involve your Regional Managers and/or Medical Directors to talk with them and convey the facilities goals and expectations.

51Overcoming Obstacles and Barriers (continued)Communication (continued):Invite the surgeon to the facility to get a first hand look at dialysis and what impact they have on the patients care and treatment.

Process:Facilities develop a communication process with the surgeons office Nephrologist/facility staff meet with the surgeon and explain the Fistula First program, facility expectations and have an agreement with the surgeon to communicate patient progress/status with the facility.

Stress the importance of continuity of care for our patients.

52Overcoming Obstacles and Barriers (continued)Nephrologists or Surgeons Not Engaged:Education:Educate nephrologists and surgeons about the Fistula First Program set up a meeting in which you can discuss the program and the facilitys goals and expectations.Refer or download resources from the Fistula First website for nephrologists and/or surgeon.

Education plays a big role in engagement of nephrologists and surgeons. They must understand the importance of vascular access care for our patient population.

Encourage your patients to ask their nephrologist or surgeon about AV fistulas and being referred for evaluation and placement. Teach them to be an advocate for their care.53Overcoming Obstacles and Barriers (continued)Communication (continued):Find ways to engage your surgeons and nephrologists (i.e. Share your facility specific data that you receive from the Network, inform them about the vascular access clubs, etc.).

Always try and find new ways to engage your nephrologists and surgeons.

Involve them in your QAPI meetings.

Share your facilitys vascular access data with them.

Encourage them to find out about access club meetings, surgical conferences, etc.54Overcoming Obstacles and Barriers (continued)Patient refuses AVF placement, patient is scared, patient is comfortable with current access, patient refuses another surgery, patients access is still functioning, etc.:

Education/Communication:Educate the patient as a team. If the patient hears the same message from different disciplines, they are more likely to believe that it is for their best interest and comply.

The first thing we should find out about these patients are if they are a candidate for and AV fistula. Have they been referred for an evaluation?

If they are a candidate, most of these issues stem from lack of education about vascular access. The key for these patients are education and repetition.

Even though you educate these patients and they refuse, periodically discuss vascular access with them always stressing the benefits of an AV fistula. Make sure you document your education and/or discussions with the patient on the patients plan of care.

Encourage nephrologists to discuss AV fistula placement with their patients.

55Overcoming Obstacles and Barriers (continued)Education/Communication (continued):Multiple patient education materials can be found on the Fistula First website. Review materials and resources with the patients/families as it applies to the patient. Encourage family support

Do not just hand these materials to the patients and or their families, sit down with them and discuss it. Have a one-on-one with the patient.

56Overcoming Obstacles and Barriers (continued)Education/Communication (continued):Designate a Vascular Access Coordinator to educate and work with these patients and have the team support his/her teaching by reiterating the same message.Facilities should conduct an in-service regarding vascular access (benefits, assessment, care, and how to teach/communicate it with the patients Involve Social Workers with teaching staff how to teach/communicate with patients.When the staff is knowledgeable about vascular access care, they can easily talk to patients about it.

57Overcoming Obstacles and Barriers (continued)Process:Ensure that your facility has a process for AV fistula referral for prevalent and incident patients.Encourage nephrologists to refer patients for evaluation while the patient is still in the hospital. If unable to do prior to discharge, encourage the nephrologist to schedule an appointment for outpatient evaluation.Ensure that your facility has a process in place for referring both prevalent and incident patients for AV fistula evaluation. By having this process the patient will know that it is just something that is done and part of the dialysis process.

58Project Summary and Expectations:Develop a Quality Assessment and Performance Improvement Plan and submit a copy to the Network (Due: November 2, 2009)Implement QAPI plan and revise as necessary during the projectMonitor your facilitys progress towards achieving the goalParticipate in monthly conference callsScheduled for the 1st Wednesdays of the month at 2pm

Develop a Quality Assessment and Performance Improvement Plan and submit a copy to the NetworkThis will be due on Monday, November 2ndScheduled for the first Wednesdays of the month at 2pm starting on November 4th.

59Project Summary and Expectations:Follow project timelines/due datesSubmit requested documentsFacility Manager Acknowledgement Letter (Due: August 27, 2009)Environmental Scan (Due: August 27, 2009)Medical Director Acknowledgement Letter (Due: September 10, 2009)QAPI Plan Signed by the Medical Director (Due: November 2, 2009)Other requested documents during the project

Submit requested documents in a timely manner.The Facility Manager Acknowledgement Letter, Environmental Scan should have already been submitted. If your facility received a delinquent notice about these documents please submit them to the Network as soon as possible.The Medical Director Acknowledgement Letter was addressed and mailed to the Medical Director. Please remind him/her to sign and return this letter.Next week you will receive a Toolkit for this project. In the toolkit will be resources and templates for the QAPI plan. The QAPI plan is in the PDSA format.Develop your plan with your interdisciplinary teamHave your Medical Director sign the plan before you submit it. The reason we are asking the Medical Director to sign the plan is because he/she is responsible for the QAPI program at your facility.The QAP plan is due on Monday, November 2nd

60ResourcesFistula First Breakthrough Initiative www.fistulafirst.org

Network 18www.esrdnetwork18.org

The toolkit with resources will be mailed to your facilities next week. Please review them and use them as they pertain to your facility. One of the tools included is the Medical Advisory Committees Catheter Reduction Toolkit.

The toolkit will include the Medical Advisory Councils Catheter Reduction Toolkit.

This toolkit was designed in a QAPI format to assist facilities in meeting the requirements of the Conditions for Coverage.

61Project Communication:To communicate more efficiently with you about this project and to be more eco-friendly, we are creating a listserv of all the facilities in this project.

In the past, we have had e-mail delivery problems with facility firewalls, please ensure you are able to receive e-mails from me about the project. Consult with your IT Department to assist you.

As weve done with previous projects, to communicate more efficiently with you about this project and to be more eco-friendly, we are creating a listserv of all the facilities in this project.

Your facilities should have provided a contact person and e-mail address on your environmental scan.

If there are any changes to this please notify me with the current or correct information.

In the past, we have had e-mail delivery problems with facility firewalls, please ensure that you are able to receive e-mails from me so that you will not miss any information about the project. Consult with your IT department to assist you with this.

62Lisle Mukai, RNQuality Improvement CoordinatorESRD Network 18323-962-2020lmukai@nw18.esrd.net

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