The State Of E In Sexas

2009 ESRD Network of Texas, Inc.2009 ESRD Network of Texas, Inc.

Network Coordinating Council Network Coordinating Council Meeting Meeting

CHAIRMAN’S REPORTCHAIRMAN’S REPORTRichard Gibney MDRichard Gibney MDRichard Gibney, MDRichard Gibney, MD

NetworkNetwork ElectionsElectionsNetwork Network ElectionsElectionsQuality ImprovementQuality ImprovementQuality Improvement Quality Improvement AA Pause to ReflectPause to ReflectA A Pause to ReflectPause to Reflect

Supporting Quality Care

NOMINATINGNOMINATING COMMITTEE 09COMMITTEE 09 1010NOMINATING NOMINATING COMMITTEE 09COMMITTEE 09--1010

Melvin Laski, LubbockMelvin Laski, LubbockRichardRichard Gibney MD WacoGibney MD WacoRichard Richard Gibney, MD, WacoGibney, MD, WacoRobert Hootkins, Robert Hootkins, MD, MD, AustinAustinCleve Collins, MD, San AntonioCleve Collins, MD, San AntonioTomTom Lowery MD TylerLowery MD TylerTom Tom Lowery, MD, TylerLowery, MD, Tyler

Slate of Officers

Melvin Laski, MD, Chairman Melvin Laski, MD, Chairman Manny Alvarez, MD, Vice ChairmanManny Alvarez, MD, Vice ChairmanLarry McGowan, TreasurerLarry McGowan, TreasurerAmy Hackney, SecretaryAmy Hackney, SecretaryRichard Gibney, MDRichard Gibney, MD

Immediate Past ChairmanImmediate Past ChairmanRuben Velez MD MRB ChairRuben Velez MD MRB ChairRuben Velez, MD, MRB ChairRuben Velez, MD, MRB ChairLaura Yates, RN,Laura Yates, RN, At LargeAt LargeCharles Orji, MD, At LargeCharles Orji, MD, At LargeCharles Orji, MD, At LargeCharles Orji, MD, At LargeLeigh Anne Tanzenburger, At LargeLeigh Anne Tanzenburger, At Large

0909--10 10 EXECUTIVE COMMITTEEEXECUTIVE COMMITTEE

Net o k Coo dinating Co ncilNet o k Coo dinating Co ncilNetwork Coordinating Council Network Coordinating Council

Election Election

Words on Quality Words on Quality

QUALITY IMPROVEMENTQURGENCY TO CHANGE:

Improve quality of care (↓harm)Improve quality of care (↓harm).

All / Patients & family benefitWin \ Staff (RN, PCT, SW, Dietitian, Physician

↓ Mortality, improve quality indicators.

Evidence based medicine, best practices, more efficient time,, p , ,patient flow.

↓Chance of liability.

Our reputation (not national average or less).

Transparency good!

It i bl & lifti t b th b t t h l i f llIt is noble & uplifting to be the best at helping our fellow man.

QUALITY IMPROVEMENTQ

“The problem with life is, p ,there is no SCARY music.”

-- Robin Williams

↓Mortality, ↓Patients Harmed.

QUALITY IMPROVEMENTQ

DATA USE:

Right things easy \ BIG GOALS!Bad things hard /

Simple & visual.

N d i tNo denominator.

“Hope is not a strategy.”

“Complexity is the enemy of reliability.”

Protocols processes systems flow (orders diagnosisProtocols, processes, systems flow (orders, diagnosis, & treatment.)

WE HAVE BEEN CALLED TO A MINISTRY,

WHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON’S LIFEWHERE WE ENTER SACRED & HOLY MOMENTS OF A PERSON’S LIFE;

A REAL AND TREASURED PRIVILEGE.

-- James Reinertsen, M.D.September, 2008

LOAVES AND FISHES

This is not the age of This is not the age of information.This is notthe age of information.

Forget the news,g ,and the radio,and the blurred screen.

This is the time of loavesand fishes.

People are hungry,and one good word is breadgfor a thousand.

--David Whyte

Report from the Executive Report from the Executive DirectorDirectorDirectorDirector

Glenda Harbert, RN, CNN, CPHQGlenda Harbert, RN, CNN, CPHQ

MISSION StatementMISSION Statement

The ESRD Network of Texas, Inc. The ESRD Network of Texas, Inc. supports quality dialysis & kidney t l t h lth th h ti t transplant healthcare through patient services, education, quality q yimprovement & data exchange.

20032003

TopicsTopicsDSHS Referrals & RulesNetwork GrowthNetwork Growth Network Activities

DSHS ESRD Licensure Rules RevisionDSHS ESRD Licensure Rules RevisionDSHS ESRD Licensure Rules Revision DSHS ESRD Licensure Rules Revision

3 Stakeholder meetingsOctober & December 08, January 09

April 1 Submit rule packet to Office of General Counsel by

June 25 ESRD rules will be proposed at the DSHS C il tiDSHS Council meeting on

30 day comment period after the proposed l bli h drules are published

No decision yet if a public comment hearing will be held during the 30 day comment periodwill be held during the 30 day comment period

DSHS responds to each comment submitted during the comment period – the comment is either accepted and the suggested change made or it is not and whymade, or it is not and why

Aft t i d fi l l blAfter comment period, final rule preamble and final rules go to HHSC for final approval

After approval, the final rules are published and become effective 30 days afterand become effective 30 days after publication

www dshs tx us/hfp/rules shtmwww.dshs.tx.us/hfp/rules.shtm

DSHS Referral UpdateDSHS Referral UpdateDSHS Referral UpdateDSHS Referral Update

Number of Cases & LevelsNumber of Cases & Levels

Common ThemesCommon ThemesCommon ThemesCommon ThemesUnsafe Infection Control Practices

Poor hand washing practicesInappropriate use of Personal Protective Equipment (PPE)(PPE)Not disinfecting surfaces

Failure to implement Quality Assessment andFailure to implement Quality Assessment and Performance Improvement (QAPI)Patient Safety Concerns

Lack of patient assessments (pre, during & post)Disabling machine alarms

Common ThemesCommon ThemesCommon ThemesCommon ThemesVascular Access Outliers

High Catheter RateLow AVF Rate

Unsafe Physical Environment Dirty floorsBroken Tiles, etc.

Water Treatment PracticesNot testing properlyLack of staff knowledgeUnsafe Reuse practicesUnsafe Reuse practices

Communication IssuesCommunication IssuesPCT’s not reporting critical treatment data/events to nurses:

Failure to reportFailure to report Hyper & Hypo tension pre, during, and post dialysis treatments

Initiating Sodium Profiling with ↑ BPInitiating Sodium Profiling with ↑ BPFailure to:

obtain accurate weightsidentify wet transducerscommunicate “Reportable Parameters” to physician or nurse

Serious SituationsSerious SituationsPatient deaths attributed to nursing practice issuesPhlebotomy of 1 liter of blood every treatment X 3 treatmentsH B i i ( ) i h dHep B positive (+) conversion then converted to negative (-) with pt. left in Isolation Room for extended periodfor extended periodInitiating dialysis when water treatment out of parametersof parameters

Serious SituationsSerious SituationsUse non-standard dialysate without appropriate monitoringpp p gFailure to recognize, report and track Adverse EventsAdverse Events

2008 Network #14 Growth & 2008 Network #14 Growth & TrendsTrendsTrendsTrends

••CMS Certified Facilities CMS Certified Facilities

•• Facility OwnershipFacility Ownership

•• Growth in Patient CensusGrowth in Patient CensusGrowth in Patient Census Growth in Patient Census

•• Patients TransplantedPatients Transplanted

Network GrowthNetwork GrowthTotal Number of Texas Dialysis FacilitiesTotal Number of Texas Dialysis FacilitiesTotal Number of Texas Dialysis FacilitiesTotal Number of Texas Dialysis Facilities

The ESRD Network of Texas, Inc.

CMS Annual Facility Survey Data

Facility Ownership in TexasFacility Ownership in Texas

26

2008 Texas Facility Ownership (%)2008 Texas Facility Ownership (%)

27

Total Number of Texas PatientsTotal Number of Texas Patients(Includes Home & In(Includes Home & In Center HD and PD Patients)Center HD and PD Patients)(Includes Home & In(Includes Home & In--Center HD and PD Patients)Center HD and PD Patients)

Total Transplants by Donor TypeTotal Transplants by Donor Type

29

20042004--20072007Standardized Transplantation Ratio Standardized Transplantation Ratio a da d d a p a a o a oa da d d a p a a o a o

(STR)(STR)

UM KECC DFR report

20072007Percent Patients (<70 years old) on Percent Patients (<70 years old) on a ( 0 y a o d) oa ( 0 y a o d) o

Transplant WaitlistTransplant Waitlist

UM KECC DFR report

2007Percent Patients on thePercent Patients on theWaitlist by Subgroup

aitli

ston

the

Wa

Subg

roup

er

cent

of S

Pe

Distribution ofDistribution of Percent of Texas FacilityPercent of Texas FacilityDistribution ofDistribution of Percent of Texas Facility Percent of Texas Facility Patients on Waitlist 2007Patients on Waitlist 2007

UM KECC DFR report

Paired donation Paired donation

Matches one incompatible donor/recipient

pair to another pair with a complimentary

incompatibilityincompatibility,

so that the donor of the first pair gives to p g

the recipient of the second, and vice

versa.

Potential DonationsPotential DonationsPotential DonationsPotential Donations

4000

5000

ange

s

3000

ble

Exch

a

•100 donor - recipient pairs generates4,950 potential paired exchanges

2000

r of P

ossi

0

1000

Num

ber

01 11 21 31 41 51 61 71 81 91 101

Number of Pairs

Alliance for Paired DonationAlliance for Paired Donation

Composed of 63 transplant centers in 22 states. 1st year APD facilitated 19 paired exchangesexchangesList of Texas Participating Centers (18)(18)www.paireddonation.org

Paired Donation NetworkPaired Donation NetworkPaired Donation NetworkPaired Donation NetworkIncludes over 80 kidney transplant programs i 23 t t th t i d i fi i lin 23 states that are organized in five regional consortia.14 p i ed dono t n pl nt h e been done14 paired donor transplants have been done within the PDN system since October 08.Texas 2 centersTexas – 2 centers

North Austin Medical CenterMemorial Hermann Renal Transplant CenterMemorial Hermann Renal Transplant Center http://www.paireddonationnetwork.org/

Activities of the Network Activities of the Network Quality Improvement OutreachOutreach

TEEC & Disaster preparednessPatient & Provider Technical Assistance &Patient & Provider Technical Assistance & Education Involuntary DischargeInvoluntary Discharge

Information Management

Quality ImprovementQuality ImprovementLab data Collection Quality Improvement ProjectsQuality Improvement Projects

Home Sweet HomeQuality of Care Concerns & CPM’sQuality of Care Concerns & CPM s

Vascular Access Improvement ProjectsSevere AnemiaSevere Anemia2 year outliers for clinical labs

Patient Services and OutreachPatient Services and OutreachPatient Services and OutreachPatient Services and Outreach

Wh t i TEEC?Wh t i TEEC?What is TEEC? What is TEEC? The mission ofThe mission ofThe mission of The mission of TEEC is to ensure a TEEC is to ensure a coordinatedcoordinatedcoordinated coordinated preparedness, plan, preparedness, plan, response and response and pprecovery to recovery to emergency events emergency events ff ti th Tff ti th Taffecting the Texas affecting the Texas

ESRD community.ESRD community.

Important Lessons LearnedImportant Lessons LearnedImportant Lessons LearnedImportant Lessons LearnedIndependent facilities must pre-plan for backup dialysis with another providerbackup dialysis with another provider

Patients should be encouraged to evacuatePatients should be encouraged to evacuate

Any patient with limited mobility supportAny patient with limited mobility, support systems and or transportation MUST be registered for evacuation with 211registered for evacuation with 211

Telling patients to go the hospital for dialysisTelling patients to go the hospital for dialysis is NOT a disaster plan!

Involuntary DischargeInvoluntary Discharge

44

54

46

32

40

31

< 0.15% of total patients

Monitoring & Profiling ComplaintsMonitoring & Profiling ComplaintsMonitoring & Profiling Complaints Monitoring & Profiling Complaints by Facilityby Facility

Percent of total Facilities withPercent of total Facilities withPercent of total Facilities with Percent of total Facilities with ComplaintsComplaints

1 Complaint 14.7%

3 Complaints 0 02%

2 Complaints 1.5%

3 Complaints 0.02%

None 83.78%

>3 Complaints 0.0%

Booklet TestBooklet TestBooklet TestBooklet Test

Fall 2008Fall 20086 facilities6 facilities-- El PasoEl Paso6 facilities6 facilities-- El Paso, El Paso, Angleton, Houston, Angleton, Houston, Tyler LubbockTyler LubbockTyler, Lubbock, Tyler, Lubbock, McAllen McAllen 55 ti t55 ti t55 patients55 patients In English and Spanish

http://www.esrdnetwork.org/patients/education/resources.asp

Test MethodTest MethodTest MethodTest Method9 volunteer RD’s were asked to participate

6 completed the test– 6 completed the test

RD’s were asked to select 9 patients (if possible) with the following characteristics to be representative of NW 14 patient g p ppopulation

– 43% Hispanic ethnicity n= 3– 57% Non-Hispanic White= 4 including 1 other race, such as

Asian if possibleAsian if possible– 30.5% Black= 2

Of the 9 patients include at leastOf the 9 patients include at least2 Non–readers1 English speaking 1 Spanish speaking1 Spanish speaking

Ask Me Three Ask Me Three Methodology*Methodology*

Selected readers were given the booklet to dread

Non readers had the booklet read to them in either English or SpanishAfter the patient read the booklet (or had it p (read to them) RD’s were asked to explain to patient : p

* National Patient Safety Foundation National Patient Safety Foundation

Non Blaming Non ShamingNon Blaming, Non Shaming

“We are testing how well we didWe are testing how well we did writing this booklet so patients can

d t d h t it I ldunderstand what it says. I would like to ask you a few questions to see how well we did.”Not:Not:

Do you understand? D h ti ?Do you have any questions?

The RD then asked 3 simple questions and recorded the answers awarding 1and recorded the answers awarding 1 point for each correct answer accepting multiple answersmultiple answers

A th t i l d d fA other category was included for answers the RD deemed correct that

t f th l t dwere not one of the pre-selected answers

Patient ScoresPatient ScoresPatient Scores Patient Scores Total score of Total score of >> 4 considered booklet 4 considered booklet effectiveeffectiveeffectiveeffective50 of 55 50 of 55 >> 4 (91%) 4 (91%) Of the 5 that did not score at least 4Of the 5 that did not score at least 4Of the 5 that did not score at least 4Of the 5 that did not score at least 4–– 1 Hispanic white spanish speaking non1 Hispanic white spanish speaking non--

readerreaderreaderreader–– 3 Non Hispanic white English reader*3 Non Hispanic white English reader*–– 1 African American English reader*1 African American English reader*–– 1 African American English reader1 African American English reader

**Although it is not known, it is possible these patients were Although it is not known, it is possible these patients were g , p pg , p pmarginal readers. It is common for adult poor readers or marginal readers. It is common for adult poor readers or nonnon--readers to deny their literacy status. readers to deny their literacy status.

Average Score by GroupAverage Score by Group

Black A/A Hispanic

White

Hispanic WhiteENG.

Hispanic White

Hispanic White

Spanish

Non Hispanic

White

Non Hispanic

WhiteBlack A/A

ENG. readerN=10

ENG. non reader

N=1

ENG. readerN=10

non reader

N=2

Spanish reader

N=5

non reader

N=7

ENG. readerN=15

Spanish reader

N=3

5.5 9 6.3 5 5.6 4.9 4.8 8.35.5 9 6.3 5 5.6 4.9 4.8 8.3

Question #1: What is the main problem? Question #1: What is the main problem? C t thi tC t thi tCorrect answer= thirstCorrect answer= thirst

What are things I can do about it? What are things I can do about it? (strategies to control thirst) (strategies to control thirst)

Percent responding

Use smaller glass , 45%

Other approved by RD as correct, 38%

Percent responding

S k

if Diabetic: Control blood sugar , 22%

Suck on ice, 51%

Use hard candy or gum , 44%

Don't eat processedeat processed meats , 25%

Why is this important for me?Why is this important for me?Why is this important for me?Why is this important for me?

Percent responding

less swelling, 35not as thirsty, 29

other , 9

Percent responding

less fluid gain, less sob, 40

64better for my heart, 60

ConclusionsConclusionsConclusionsConclusionsThe booklet effectively educated patients f l d hi diof several demographics regarding:

– The main topic- with 95% answering thirst correctlycorrectly

– Strategies to control thirst 22-51% cited >1 of 5 answers determined in22 51% cited >1 of 5 answers determined in advance to be correct38% cited another answer that the RD approved as correctas correctSuck on ice was the strategy scoring the highest (51%)

Conclusions, continuedConclusions, continued– Importance to them personally

29-64% cited >1 of 5 answers determined29 64% cited >1 of 5 answers determined in advance to be correctLess fluid gain was the reason scoring the g ghighest (64%) Better for my heart second highest (60%) y g ( )9% cited another answer that the RD approved as correct

Why do all that for a booklet Why do all that for a booklet yyeveryone likes & uses? everyone likes & uses?

Need to show effectiveness of outreach to CMSLearning new methods to address

Health Literacy issuesHealth Literacy issuesDemonstrating effectiveness

Health Literacy: A Prescription to End Health Literacy: A Prescription to End Confusion. Confusion.

90 million US adults: literacy skills below high school levelschool levelAdults with limited literacy:

less knowledge of disease management & health i b h ipromoting behaviors

report poorer health statusless likely to use preventive servicesy phigher hospitalization rates & emergency service use less adherenceless adherence

>300 studies show health-related materials far exceed average reading ability of US adults

Institute of Medicine 2004Institute of Medicine, 2004

Health Literacy of American AdultsHealth Literacy of American Adults

National Assessment of Adult Literacy (NAAL): NationalCenter for Educational Statistics, U.S.Department of Education, 2003.

Health Literacy“The degree to which individuals have the capacity to;p y ;

obtain,process, andprocess, and understand

basic health information and servicesbasic health information and services needed to make appropriate health decisions ”decisions.

Healthy People 2010

Improves Patient Safety A 2006 study examined patients’ abilities to understand five common instructions on prescription medications.

Both patients with adequate and low literacy had difficulty understanding atliteracy had difficulty understanding at least one of the five instructions.

““What Did the Doctor SayWhat Did the Doctor Say?”*?”*

Recommends making plain language a

yy

“universal precaution” in all patient encounters

*Improving Health Literacy to Protect Patient Safety- Joint CommissionSafety- Joint Commission

What is plain language?What is plain language?

• Plain language is communication that an audience can understand the first time they read or hear it

What is plain language?What is plain language?

Whatunderstand the first time they read or hear it.

Why• The concept of using plain language is closely related to

the concept of health literacy.y

• Clear communication is critical to successful health careHow

• Clear communication is critical to successful health care.

Watch for more information onWatch for more information onWatch for more information on Watch for more information on Health Literacy and Patient EducationHealth Literacy and Patient Education

What happened to Crown Web?What happened to Crown Web?

•Phase I- Pilot Project with 4 Networks & 8 F ilitiFacilities •Phase II ? Spring or Summer 09F ll I l t ti ??•Full Implementation ??

•For more Information- Special Session S t d AftSaturday Afternoon

Thank you for all that you doThank you for all that you doThank you for all that you doThank you for all that you do

[email protected]@nw14.esrd.net469469--916916--38013801469469 916916 38013801

Report fromReport fromMedical Review Board Medical Review Board (MRB)(MRB)

ChairmanChairmanChairmanChairman

R b t H tki MD PhD FACP FASNR b t H tki MD PhD FACP FASNRobert Hootkins MD, PhD, FACP, FASNRobert Hootkins MD, PhD, FACP, FASN

My Assignment Today!My Assignment Today!y g yy g y

Review geographic representationReview geographic representationReview geographic representation Review geographic representation and functions of MRBand functions of MRB

Share current NW #14 clinical Share current NW #14 clinical indicator data indicator data

Closing thoughts as outgoing Closing thoughts as outgoing “lame duck” Chairman“lame duck” Chairmanlame duck Chairmanlame duck Chairman

MRB FunctionsMRB FunctionsEvaluate quality and appropriateness of care Evaluate quality and appropriateness of care delivered to ESRD patients in Texasdelivered to ESRD patients in Texas

Propose Corrective Action Plans (CAP) for dialysis Propose Corrective Action Plans (CAP) for dialysis units with Level 2units with Level 2--3 deficiencies3 deficiencies to Texas to Texas Department of State Health Services (DSHS)Department of State Health Services (DSHS)Department of State Health Services (DSHS) Department of State Health Services (DSHS)

Analyze NW #14 data and recommend clinical Analyze NW #14 data and recommend clinical outcome profiling cutoutcome profiling cut--pointspointsoutcome profiling cutoutcome profiling cut pointspoints

Serve as primary advisory panel to Network to Serve as primary advisory panel to Network to promotepromote improvedimproved patient care and safetypatient care and safetypromote promote improvedimproved patient care and safety patient care and safety through QI activitiesthrough QI activities

Utilize NW #14 data to identify NetworkUtilize NW #14 data to identify Network--wide wide yyimprovement opportunitiesimprovement opportunities

Current Geographic Current Geographic Representation of MRBRepresentation of MRBRepresentation of MRB Representation of MRB

Ruben Velez, MDRuben Velez, MDCamille May, RNCamille May, RNI D id MDI D id MDIngemar Davidson, MDIngemar Davidson, MDTrish White, RNTrish White, RNMary Beth Callahan, SWMary Beth Callahan, SWDianne MorganDianne Morgan

Jennie Lang House, RDJennie Lang House, RD

James Cotton, MDJames Cotton, MD

a e o gaa e o ga

Mohan Narayan, MDMohan Narayan, MDStuart Goldstein ,MDStuart Goldstein ,MDDonald Molony, MDDonald Molony, MDJane Louis, RDJane Louis, RDJ li L i MDJ li L i MD

Robert Hootkins, MDRobert Hootkins, MDDeborah Heinrich, RNDeborah Heinrich, RN

Mohan Narayan, MDMohan Narayan, MD

Jacqueline Lappin, MDJacqueline Lappin, MDDenise Hart, MD Denise Hart, MD MazeenMazeen ArarArar, MD, MDJoyce Hernandez, SWJoyce Hernandez, SW Clyde Rutherford MDClyde Rutherford MD


y ,y ,Anna GonzalezAnna GonzalezNavidNavid SaigalSaigal, MD, MD

Clyde Rutherford, MDClyde Rutherford, MD

Kaylenne Duran, RN

Information onInformation onInformation on Information on Data & ProjectsData & ProjectsData & ProjectsData & Projects

ESRD Network of Texas, Inc. ESRD Network of Texas, Inc.

Comparative Clinical Indicator Data used by NW #14

Data Collection MandatingOrganization Sample Size Comparative

Data Level Use

Clinical Random Network IdentifyClinical Performance

Measures (CPM)CMS

Random Sample Patients

and U.S.(No Facility

Specific Data)

Identify NW QI

Projects

Quality of Care(QOC)

Indicator ProjectNetwork #14

100% of eligible patients

Facility, Network and

U.S.

Identify outlier

facilities

Fistula First CMS 100% of patients


U.S.

Identify VA outlier facilities

Annual DialysisFacility Report CMS

All facility patients with URR and ESA

Medicare


U.S.

Data posted on DFC and used by Medicare

Billing Claims SMR, SHR, STR State Surveyors

HemodialysisHemodialysisHemodialysis Hemodialysis AdequacyAdequacyAdequacyAdequacy

Percent of PatientsPercent of Patientswith URR with URR >> 65% 65% -- CPMCPM

90 90 90 90 90 90 9089 89 89 89 89 8990

9294 89% 90%

89 89 89 89 89 8988 88 88

87

85868890

Patie

nts

83

808284

% o

f P

7678

14 4 6 8 12 1 16 3 9 11 13 15 US 2 7 18 10 5 17

Network


Percent of PatientsPercent of Patientswith Kt/V with Kt/V >> 1.2 1.2 -- CPMCPM

93%

93 93 93 93 93 93

92 92 92 92 92

91 91 91929394 91%

91 91 91

90 90 90

89899091

Patie

nts

87

86878889

% o

f P

848586

14 4 8 9 1 16 3 6 7 12 18 13 15 US 2 10 11 5 1714 4 8 9 1 16 3 6 7 12 18 13 15 US 2 10 11 5 17

NetworkThe ESRD Network of Texas, Inc.

MRB Quality of Care Cut-Point for HD Adequacy (2007 data)

More than 80% of facility patients have a URR of > 65%

95% of TX HD facilities (N= 391) met or 95% of TX HD facilities (N= 391) met or d d th MRB lit td d th MRB lit t i t!i t!exceeded the MRB quality cutexceeded the MRB quality cut--point!point!

What about the 5% of TX facilities (N=19) that What about the 5% of TX facilities (N=19) that did ’did ’ h ih ididn’t meetdidn’t meet the cut point?the cut point?

14 facilities 14 facilities 7171--80% 80% of patients had a URR of patients had a URR >> 65%65%

3 facilities3 facilities 6161--70%70% of patients had a URRof patients had a URR >> 65%65%3 facilities 3 facilities 6161--70% 70% of patients had a URR of patients had a URR >> 65%65%

1 facility 1 facility 5151--60%60% of patients had a URR of patients had a URR >> 65%65%

1 facility 1 facility 00--10%10% of patients had a URR of patients had a URR >> 65%65%

HemodialysisHemodialysisHemodialysis Hemodialysis Anemia ManagementAnemia ManagementAnemia ManagementAnemia Management

Percent of PatientsPercent of Patientswith HGB < 10.0 with HGB < 10.0 -- CPMCPM

7 7 7

8

789

5% 5%

4 4 4

5 5 5 5 5 5 5 5

6 6 6

567

Patie

nts

3

234

% o

f P

01

17 1 15 18 14 4 6 7 US 3 16 10 5 12 13 8 9 11 2

Network


Percent of PatientsPercent of Patientswith HGB with HGB >> 11.0 11.0 -- CPMCPM

86%

8685

84 8484

86

8882%

86%

83 83 8382 82 82 82

81 81 8180 80 80 80

80

82

84

Patie

nts

77

76

78

% o

f P

72

74

14 1 17 18 3 7 15 11 US 16 12 5 6 10 4 8 9 13 2

Network


Percent of PatientsPercent of Patientswith HGB 11.0with HGB 11.0--12.0 12.0 -- CPMCPM44%

45 4442 42 42 42 41 41 40 39 39 38 37 37 3740

4550 39%

44%

38 37 37 37 36 3633 32

25303540

Patie

nts

10152025

% o

f P

05

10

1 14 3 4 16 17 15 18 2 US 10 5 9 11 12 7 8 6 131 14 3 4 16 17 15 18 2 US 10 5 9 11 12 7 8 6 13


MRB Quality of Care Cut-PointMRB Quality of Care Cut Point for HD Severe Anemia Management (2007 data)

Less than 11% of facility patients have a Hemoglobin < 10.0

94% of TX HD facilities (N=413) met or exceeded94% of TX HD facilities (N=413) met or exceeded

Less than 11% of facility patients have a Hemoglobin 10.0

94% of TX HD facilities (N=413) met or exceeded 94% of TX HD facilities (N=413) met or exceeded the MRB quality cutthe MRB quality cut--point!point!

What about the 6% of TX facilities (N=26) thatWhat about the 6% of TX facilities (N=26) thatWhat about the 6% of TX facilities (N=26) that What about the 6% of TX facilities (N=26) that didn’t meetdidn’t meet the cut point for this Hgb range?the cut point for this Hgb range?

23 facilities 23 facilities 1111--2020 %% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

1 facility 1 facility 2121--3030%% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

1 facility 1 facility 4141--50% 50% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.000

1 facility1 facility 9191 100100%% of patients with Hemoglobin <of patients with Hemoglobin < 10 010 01 facility 1 facility 9191--100100% % of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

MRB Quality of Care Cut-Point for HD Anemia Management (2007 data)

More than 70% of facility patients have aH l bi b 10 0 d 13 0 /dl

90% of TX HD facilities (N= 370) met or exceeded90% of TX HD facilities (N= 370) met or exceeded

Hemoglobin between > 10.0 and < 13.0 gm/dl

90% of TX HD facilities (N 370) met or exceeded 90% of TX HD facilities (N 370) met or exceeded the MRB quality cutthe MRB quality cut--point!point!


30 facilities 30 facilities 60.160.1--70%70% of patients of patients >> 10.0 10.0 andand < 13.0 gm/dl< 13.0 gm/dl

8 facilities 8 facilities 50.50.11--60%60% of patients of patients >> 10.0 10.0 and and < 13.0 gm/dl< 13.0 gm/dl

4 facility 4 facility 40.140.1--50% 50% of patients of patients >> 10.0 10.0 andand < 13.0 gm/dl< 13.0 gm/dl

1 facility1 facility 00--10%10% of patientsof patients >> 10.010.0 andand < 13.0 gm/dl< 13.0 gm/dl1 facility 1 facility 00 10%10% of patients of patients 10.0 10.0 andand 13.0 gm/dl 13.0 gm/dl

HemodialysisHemodialysisHemodialysis Hemodialysis Bone and MineralBone and MineralBone and Mineral Bone and Mineral

MetabolismMetabolismMetabolismMetabolism

Percent of PatientsPercent of Patientswith Phosphorus 3.5with Phosphorus 3.5--5.5 5.5 -- CPMCPM

58%

49 50 51 51 51 52 52 52 53 53 54 54 55 55 56 57 5860

70 52% 58%

4548 49 50 51 51 51

40

50

Patie

nts

20

30

% o

f P

0

10

6 7 16 5 8 13 17 9 11 US 3 15 10 12 1 18 2 4 146 6 5 8 3 9 US 3 5 0 8

Network


Peritoneal DialysisPeritoneal DialysisPeritoneal Dialysis Peritoneal Dialysis AdequacyAdequacyAdequacyAdequacy

Percent of PD PatientsPercent of PD Patients

2006 2007

with Kt/V with Kt/V ≥ 1.7 ≥ 1.7 -- QOCQOC

91.1 89.99095

1002006 2007

75808590

ents

60657075

% o

f Pat

ie

45505560%

4045


MRB Quality of Care Cut-Point for PD Adequacy (2007 data)

More than 80% of facility patients have a Kt/V > 1.7

75% of TX PD facilities (N= 84) met or exceeded 75% of TX PD facilities (N= 84) met or exceeded th MRB lit tth MRB lit t i t!i t!the MRB quality cutthe MRB quality cut--point!point!

What about the 25% of TX facilities (N=28) that What about the 25% of TX facilities (N=28) that did ’did ’ h ih ididn’t meetdidn’t meet the cut point?the cut point?

18 facilities 18 facilities 7171--80% 80% of patients met of patients met Kt/V > 1.7

2 facilities2 facilities 6161--70%70% of patients metof patients met Kt/V > 1 72 facilities 2 facilities 6161--70% 70% of patients met of patients met Kt/V > 1.7

1 facility 1 facility 5151--60%60% of patients met of patients met Kt/V > 1.7

7 facilities 7 facilities 00--50%50% of patients met of patients met Kt/V > 1.7

Peritoneal DialysisPeritoneal DialysisPeritoneal Dialysis Peritoneal Dialysis Anemia ManagementAnemia ManagementAnemia ManagementAnemia Management

Percent of PD Patients with Percent of PD Patients with HGBHGB << 10 010 0 QOCQOCHGB HGB << 10.0 10.0 -- QOCQOC


Percent of PD Patients Percent of PD Patients ith HGBith HGB ≥≥ 11 011 0 QOCQOC

90

with HGB with HGB ≥ ≥ 11.0 11.0 -- QOCQOC

81.985

902000 2001 2002 20032004 2005 2006 2007

73 8

77.179.1

80.478.380

tient

s

69.2

73.8

70

75

% o

f Pat

65

%

60


Percent of PD Patients Percent of PD Patients ith TSATith TSAT ≥≥ 20%20% QOCQOCwith TSAT with TSAT ≥ ≥ 20% 20% -- QOCQOC


MRB Quality of Care Cut-PointMRB Quality of Care Cut Point for PD Severe Anemia Management (2007 data)

Less than 11% of facility patients have a Hemoglobin < 10.0

77% f TX PD f iliti (N 77) t d d th77% f TX PD f iliti (N 77) t d d th

Less than 11% of facility patients have a Hemoglobin 10.0

77% of TX PD facilities (N=77) met or exceeded the 77% of TX PD facilities (N=77) met or exceeded the MRB quality cutMRB quality cut--point!point!

Wh t b t th 23% f TX f iliti (N 26) th tWh t b t th 23% f TX f iliti (N 26) th tWhat about the 23% of TX facilities (N=26) that What about the 23% of TX facilities (N=26) that didn’t meetdidn’t meet the cut point for this Hgb range?the cut point for this Hgb range?

14 facilities 14 facilities 1111--2020 %% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

6 facilities 6 facilities 2121--3030%% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

6 facilities 6 facilities 4141--50% 50% of patients with Hemoglobin <of patients with Hemoglobin < 10.010.0

MRB Quality of Care Cut-Point for PD Anemia Management (2007 data)

More than 70% of facility patients have aH l bi b 10 0 d 13 0 /dl

66% of TX PD facilities (N=77) met or exceeded the66% of TX PD facilities (N=77) met or exceeded the

Hemoglobin between > 10.0 and < 13.0 gm/dl

66% of TX PD facilities (N=77) met or exceeded the 66% of TX PD facilities (N=77) met or exceeded the MRB quality cutMRB quality cut--point!point!


19 facilities 19 facilities 60.160.1--70%70% of patients of patients >> 10.0 10.0 and and < 13.0 gm/dl< 13.0 gm/dl

6 facilities 6 facilities 50.50.11--60%60% of patients of patients >> 10.0 10.0 andand < 13.0 gm/dl< 13.0 gm/dl

9 facilities 9 facilities 40.140.1--50% 50% of patients of patients >> 10.0 10.0 andand < 13.0 gm/dl< 13.0 gm/dl

6 facilities6 facilities 00--40%40% of patientsof patients >> 10 010 0 andand < 13 0 gm/dl< 13 0 gm/dl6 facilities 6 facilities 00--40%40% of patients of patients >> 10.0 10.0 and and < 13.0 gm/dl< 13.0 gm/dl

Peritoneal DialysisPeritoneal DialysisPeritoneal Dialysis Peritoneal Dialysis AlbuminAlbuminAlbuminAlbumin

Percent of PD Patients Percent of PD Patients ith ALBith ALB ≥≥ 4 0/3 74 0/3 7 QOCQOC

36

with ALB with ALB ≥ ≥ 4.0/3.7 4.0/3.7 -- QOCQOC

27.424 828

32

362000 2001 2002 20032004 2005 2006 2007

24.823.0

20.3 21.3 20.620

24

28

atie

nts

12

16

% o

f Pa

4

8

0The ESRD Network of Texas, Inc.

Vascular AccessVascular AccessVascular Access Vascular Access ManagementManagementManagementManagement

AVF Utilization in the U.S.AVF Utilization in the U.S.November 2008November 2008

70 64

57 57 56 55 5552 51 51 51 51 50 50 50 49 48 48

60

70 51.4% 50.5%

50 50 50 49 48 48 47 47

40

50

nt A

VF

20

30

Perc

e

0

10

16 15 17 1 2 18 3 7 US 12 14 4 11 13 10 5 8 9 616 15 17 1 2 18 3 7 US 12 14 4 11 13 10 5 8 9 6


Improvement Needed to Meet CMS Contract Year Goal of 4%CMS Contract Year Goal of 4%

2008-2009 AVF Gap Analysis Trending - Network #14Where we are now and where we NEED TO BE to meet

our CMS goal of 4% increase in prevalent AVFs

52.0%

52.8%

our CMS goal of 4% increase in prevalent AVFs Assuming Equal Growth each Month

Where we need to be Where we are/were

50.3% 50.6% 50.9% 51.2%

51.5%51.8%

52.0%

51.2%

52.0%

Rat

e

49.1%49.4%

49.7%50.0%

49.6% 49.8% 49.9% 50.0%

50.4%50.5%

49.6%

50.4%

AVF

R

48.5%48.8%

49.1%

48.5% 48.6%48.8%

9 6%

48.0%

48.8%

M 08 A 08 M 08 J 08 J l 08 A 08 S 08 O t 08 N 08 D 08 J 09 F b 09 M 09Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09Month

Percent of Prevalent PatientsPercent of Prevalent Patientswith Catheterwith Catheter ((with/without AVF or AVG,with/without AVF or AVG,with Catheter with Catheter ((with/without AVF or AVG, with/without AVF or AVG,

regardless of duration of useregardless of duration of use) ) -- CPMCPM

31 31 31 32 32 323435

40 27%

21%

21 2123 24 24 25

27 27 27 28 28 28

20

25

30

Patie

nts

21%

10

15

20

% o

f P

0

5

14 18 16 1 6 8 15 17 US 2 3 4 11 12 13 7 9 10 514 18 16 1 6 8 15 17 US 2 3 4 11 12 13 7 9 10 5


Percent of Prevalent PatientsPercent of Prevalent Patientswith Catheter with Catheter -- CPMCPM

2123 24

2125

30

1719

21 21

15

20

atie

nts

10

15

% o

f P

0

5

2002 2003 2004 2005 2006 2007

Network 14The ESRD Network of Texas, Inc.

September 2008

Chart 2: Prevalent Texas Patients With Catheter Only

9.310

12

ents

Oct 2003 Oct 2004 Sep 2005 Sep 2006 Sep 2007 Mar 2008 Sep 2008

5.6

8.4

5 26.2

8.9

5.6

8.3

5 1

8.0

5.6

8.1

5 2

7.9

6

8

10

vale

nt P

atie

5.6 5.2 5.6 5.1 5.6 5.2

2

4

6

cent

of P

rev

0

2

Perc

Utilizing CatheterUtilizing Catheter> 90 Days< 90 Days

Percent of Prevalent PatientsPercent of Prevalent Patientswith AV Graft with AV Graft -- CPMCPM

31%

26

30 3130

3522%

31%

15 16 16 17 18 19 20 21 22 22 22 23 23 23 2326

20

25

atie

nts

14 15 6 6

10

15

% o

f Pa

0

5

16 15 1 12 7 10 2 17 3 5 13 US 4 9 11 18 8 6 1416 15 1 12 7 10 2 17 3 5 13 US 4 9 11 18 8 6 14


Percent of Prevalent PatientsPercent of Prevalent Patientswith AV Graft with AV Graft -- CPMCPM

5652

4450

60

44

32 32 3130

40

atie

nts

20

30

% o

f Pa

0

10

2002 2003 2004 2005 2006 20072002 2003 2004 2005 2006 2007


Percent of Prevalent Patients with Percent of Prevalent Patients with AVG dAVG d S iS i M i iM i i CPMCPMAVG and AVG and StenosisStenosis Monitoring Monitoring -- CPMCPM

99

87 84100

12071%

69% 87 84 8072 72 72 71 71 71 71 69 67 67 64 62 62 61 5860

80

Patie

nts

20

40

% o

f P

0

20

16 13 6 4 3 8 11 1 10 18 US 14 12 17 2 9 15 7 5

Network


Percent of Prevalent Patients with Percent of Prevalent Patients with AVG dAVG d S iS i M i iM i i CPMCPMAVG and AVG and StenosisStenosis Monitoring Monitoring -- CPMCPM

90

100

78

84

80

90

atie

nts

6872 72

6970

% o

f Pa

50

60

2002 2003 2004 2005 2006 2007


Fistula First FocusFistula First FocusNephrologist awareness and early referral Nephrologist awareness and early referral patternspatternsppRegional areas with system barriersRegional areas with system barriersAVG conversion to Secondary AVFAVG conversion to Secondary AVFAVG conversion to Secondary AVF AVG conversion to Secondary AVF

Focus on Assessing Failing AVG for conversion to Secondary AVFSecondary AVF Pilot Project Ongoing- 6 Texas Facilities with historically high AVG rates (> 30% AVG x 3 years)

NephrologistNephrologist Profile Report:Profile Report:

Cath + AVFor AVG AVF

Physician Texas

AVF

AVG

Cath + AVFor AVG

Physician Texas

Catheter Only Catheter Only

N N2 4190 153

C th t ith C th t ithAVG 0.0 AVG 8.9AVF 12.5 AVF 24.2

Physician % Texas %

12 72616 1729Total 100.0 Total 100.0

431 24.9

Catheter Only 75.0 Catheter Only 42.0

Catheter with AVF or AVG 2 12.5 Catheter with

AVF or AVG

VA Used for First Chronic Dialysis Patients with > 12VA Used for First Chronic Dialysis Patients with > 12


VA Used for First Chronic Dialysis Patients with > 12 VA Used for First Chronic Dialysis Patients with > 12 Months Months NephrologistNephrologist PrePre--ESRD CareESRD Care

AVF Prevalent AVF in Texas 03AVF Prevalent AVF in Texas 03--0808

Distributiion of Percent AVF Rate

140

100

120

acili

ties

60

80

Num

ber o

f Fac

Sep '08 Sep '07 Sep '06Sep '05

20

40N

Sep 05 Sep '04 Oct '03

10 20 30 40 50 60 70 80 90

Percent AVF Rate

0

Other NW data &Other NW data &Other NW data & Other NW data & QI ProjectsQI ProjectsQI ProjectsQI Projects

20042004--2007200720042004 20072007Standardized Mortality Ratio (SMR)Standardized Mortality Ratio (SMR)

St ti ti ll Si ifi t SMR 2004St ti ti ll Si ifi t SMR 2004 20072007Statistically Significant SMR 2004Statistically Significant SMR 2004--20072007

HighHigh LowLowHigh High 28 Facilities28 FacilitiesSMR rangeSMR range 1.221.22-- 2.132.13

Low Low 41 Facilities 41 Facilities SMR rangeSMR range 0.000.00--0.740.74SMR range SMR range 1.221.22 2.132.13

P value range 0.000P value range 0.000--0.260.26Patient Census 38Patient Census 38--312312

SMR range SMR range 0.000.00 0.74 0.74 P value range 0.00P value range 0.00--0.0490.049Patient Census 29Patient Census 29--372372

MRB follow up in progressMRB follow up in progress

20042004--20082008Patients Patients on on IncenterIncenter & Home & Home DialysisDialysis

ents

er o

f Pat

ieN

umbe

Increasing Home DialysisIncreasing Home DialysisIncreasing Home Dialysis Increasing Home Dialysis Quality Improvement ProjectQuality Improvement Project

Benchmark facility resultsBenchmark facility results

Important practices in Important practices in educating, referringeducating, referring, & , & recruiting patients for homerecruiting patients for home dialysisdialysisrecruiting patients for home recruiting patients for home dialysisdialysis

Staff member(s) assigned to role of home dialysis patient education specialist or coordinator.

Facility has a strong physician advocate for home dialysis.

Facility has a separate Home Dialysis Program with separate staff from the in-center program.

Facility has processes that empower nurses & SWs to educate patients & encourage home dialysis.

Facility has formal home dialysis patient education protocol initiated on all new patients.

Important practices in Important practices in educating, referringeducating, referring, & , & recruitingrecruiting patients for homepatients for home dialysisdialysisrecruiting recruiting patients for home patients for home dialysisdialysis

New staff receive education on home dialysis during orientation & regularly.

Reassess new patients' suitability for home dialysis 3 and 6 months after dialysis is initiated & then annually.

Home Dialysis “awareness days” done for in-center HD

New patients re-educated on home dialysis options 3 and 6 months after dialysis is initiated.

Referral assessment tool with specific criteria utilized to determine suitability for home dialysis.

Change in facilities with Home Change in facilities with Home P ti tP ti tPatientsPatients

Baseline 2006Baseline 2006 After Project 2008After Project 2008Baseline 2006Baseline 2006 After Project 2008After Project 2008

ImprovingImprovingImproving Improving Management ofManagement ofManagement of Management of

PhosphorusPhosphorusPhosphorus Phosphorus OutcomesOutcomesOutcomes Outcomes

Rationale and GoalsRationale and GoalsPhosphorus is important Phosphorus is important

MortalityMortalityMortalityMortalityQuality of LifeQuality of LifeThere is variability across facilitiesThere is variability across facilitiesThere is variability across facilitiesThere is variability across facilities

Project GoalsProject GoalsIncrease percent of patients in target rangeIncrease percent of patients in target rangeIncrease percent of patients in target rangeIncrease percent of patients in target range

Distribution of Facilities By Percent of PDDistribution of Facilities By Percent of PDPatients withPatients with Serum Phosphorus 5 5 mg/dlSerum Phosphorus 5 5 mg/dl or Loweror LowerPatients with Patients with Serum Phosphorus 5.5 mg/dl Serum Phosphorus 5.5 mg/dl or Loweror Lower

QOC ConcernOpportunityto Improve Benchmarksto Improve

2007 Quality of Care Project (4th Quarter 2006 data)Mean = 62.8St Dev = 25.71

Observational Data Have Shown Elevated Serum Observational Data Have Shown Elevated Serum Phosphorus Levels Are Associated With Increased MortalityPhosphorus Levels Are Associated With Increased Mortality

Study Data Population N PO4 (mg/dL)

Increased Relative Risk

Sli i Y t lSli i Y t l 19931993 19961996 DMMSDMMS 14 82914 829 5 45 4 6 36 3 2%2%Slinin Y, et al.Slinin Y, et al. 19931993--19961996 DMMSDMMS 14,82914,829 5.45.4--6.36.36.46.4--7.57.5> 7.5> 7.5

2%2%10%10%19%19%

Melamed EW etMelamed EW et 19951995--19981998 CHOICECHOICE 593593 5 15 1--6 0*6 0* 8%8%Melamed EW, et Melamed EW, et al.al.

19951995--19981998 CHOICECHOICE 593593 5.15.1--6.0*6.0*> 6.0*> 6.0*

8%8%57%57%

Block GA, et al.Block GA, et al. 19971997 FMC FMC DatabaseDatabase

40,53840,538 5.05.0--5.55.55.55.5--6.06.0

10%10%25%25%5.55.5 6.06.0 25%25%

Young EW, et al.Young EW, et al. 19961996--20012001 DOPPSDOPPS 17,23617,236 Per 1 Per 1 mg/dLmg/dL

4%4%

KalantarKalantar--Zadeh, Zadeh, 20012001--20032003 DaVita DaVita 58,05858,058 >> 6.0*6.0* IncreasedIncreased††et al.et al. DatabaseDatabase

*Adjusted for vitamin D administration.†Exact number not specified.

Continuing Opportunities for Continuing Opportunities for g ppg ppImprovement in TexasImprovement in Texas

Barriers: Funding & NW ResourcesBarriers: Funding & NW ResourcesBarriers: Funding & NW ResourcesBarriers: Funding & NW Resources

P t ti l P j tP t ti l P j tPotential Projects:Potential Projects:K+ Baths / Protocols K+ Baths / Protocols Abx/Cult Practices Abx/Cult Practices –– Protocols?Protocols?Catheter ManagementCatheter ManagementCatheter ManagementCatheter Management

Closing thoughtsClosing thoughtsSafety / RisksSafety / Risks

Staff Oversight / VigilanceStaff Oversight / VigilanceStaff Oversight / VigilanceStaff Oversight / VigilanceDSHS CollaborationDSHS CollaborationM di l Di t C it tM di l Di t C it tMedical Director CommitmentMedical Director Commitment

“We Can Do Better”“We Can Do Better”

“The medical direction of dialysis facilities has been sometimes absent feckless* orhas been … sometimes absent, feckless or uninspired”

*lacking purposewithout skillineffective, incompetent

G t 2007

, placking the courage to act in any meaningful way

Gutman, 2007

CMS 2744 (2004-2006) Annual Facility Survey Data

FistulaFistula FirstFirst S dS dRegional Regional FistulaFistula First First

Dashboard DataDashboard DataSecondary Secondary AVF VAIPAVF VAIP

ggCollaborative Collaborative VA WorkshopsVA Workshops

&

Quality of Care Quality of Care “Concern” Facilities“Concern” Facilities

Quality of Care Quality of Care Indicator Data Indicator Data

CMS 2728 (2007)CMS 2728 (2007)Medical Evidence Report FormMedical Evidence Report Form

Access in Use at Access in Use at Initiation of DialysisInitiation of Dialysis

Clinical Performance Improving Phosphorous

Medical Evidence Report FormMedical Evidence Report Form yy

Measures (CPM) Data Phosphorous Management

Recognitionsg

The State Of E In Sexas

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