How Do You Measure

Quality in Your Facility? David E. Henner, DO

• Division Chief of Nephrology:

• Berkshire Medical Center (BMC)

• Medical Director/Administrator of Dialysis:

• BMC Central County Dialysis Center

• BMC South County Dialysis Center

• BMC North County Dialysis Center

• Medical Director/Administrator of Dialysis:

• Southwestern Vermont Medical Center (SVMC)

• Medical Advisory Council (MAC) Chair

• National ESRD Forum of Networks

• Medical Review Board (MRB) Chair

• ESRD Network 1 (IPRO ESRD Network of New England)

Topics to be Reviewed

QAPI Measures tracked:

• QIP Measures

• Core Survey Measures

• Network QIA Measures

• Other Measures

Method to track measures in QAPI process

• QMAT

Using QMAT to Improve Care of Individual Patients

Other uses of QAPI and QMAT Data:

• Nephrologist quality metrics

• Network QIAs

• Research studies

Quality Metrics:

Monitoring past 10 years

• CQI Meetings

• Reporting lab results to Networks

• CMS DFRs

• Network Elab Project

• 2008- ESRD Conditions for Coverage

• Interpretive Guidance

• MAT

• QAPI

• 2011- PPS (Bundle)

• QIP

• CROWNWeb

• 2014- DFC, 5 Star Ratings

• 2014 Core Survey

Homer W. Smith: “Though we name the things we know, we don’t necessarily know them because we name them”

CMS Measures Assessment Tool (From ESRD Conditions for

Coverage Interpretive Guidance)

6

MAT

7

MAT

ESRD Quality Incentive

Program (QIP)

9

10

11

12

13

14

New Proposed QIP/PPS Rule

• UFR and Depression: incorporated into domains

• Reporting measure domain removed

• Patient and Family Engagement: new separate domain

• Removed reporting measures:

• Pain

• Phosphorus

• Anemia

• Dialysis facility staff influenza rates

• New Proposed Measures:

• Transplant- % of prevalent pts waitlisted- PPPW-PY 2022

• Standardized Incident pt waitlisted rate- SWR- PY 2024

• Medication Reconciliation- PY 2022

16

Comments to CMS on

Proposed rule

• Forum of ESRD Networks submitted comments regarding most of

the measures

• MAC: involved comments/discussions from MRB Chairs from

each network

• KPAC: patient perspective taken into account

• Comments were due 9/10/2018

“Half the people you know

are below average.”

Steven Wright

ESRD Core Survey

Measures

Core Survey Readiness

• Core Survey Data Worksheets completed and updated monthly

• Binder containing all data needed for Core Survey ready and

updated monthly

• Policies

• Water Testing results

Steven Wright

“When everything is coming your way, you're in the wrong lane.”

QAPI Measures

QAPI Measures: QIP

QAPI: QIP Measures Continued

QAPI Core Survey Measures:

In-Center HD

QAPI: Core Survey Measures

PD

QAPI: KDQOL, Grievances, Water

QAPI: Audits

QAPI: Audits continued

QAPI: Access, Mortality and

other data review

Steven Wright

“99% of lawyers give the rest a bad name.”

How Do You Get the Data for QAPI and Core Survey?

QMAT Index

QMAT: Adequacy Summary:

Filter Frequency to 3x/week

QMAT: Adequacy Summary:

Double click for detail pt level data

QMAT: Adequacy detail: No PHI

Filter months, sort alphabetically

QMAT: Adequacy detail: No PHI

Filter for pts without Kt/V >1.2

QMAT: Adequacy detail: Alphabetical

List pts with Kt/V<1.2 for 2 months

• Pt names for Core Survey Data Tool

QMAT: Anemia Summary:

Filter ESA use vs all pts

QMAT: Anemia Summary:

Double click for detail pt level data

QMAT: Anemia detail: No PHI

Filter for 2 months of data

QMAT: Anemia detail: No PHI

Filter for pts with Hgb < 10 g/dL

QMAT: Anemia detail: Alphabetical

List pts with Hgb < 10 g/dL for 2 months

• Pt names for Core Survey Data Tool

• Current ESA Dose

• Hgb Levels

QMAT: Access Summary:

Filter Clinics, months, status

QMAT: Access Detail

Filter for pts CVC>90 Days

QMAT: Access Detail- Alphabetical

List pts with CVC in use >90 days

• Pt names for Core Survey Data Tool

Yogi Berra

“We’re lost, but we’re making good time!”

QMAT: Fluid Management Summary:

Filter Clinics, months, status

QMAT: Fluid Management Detail:

Filter for pts with Avr UFR > 13 ml/kg/hr

QMAT: Fluid Management Detail- Alphabetical

List pts with Avr UFR>13 ml/kg/hr per month

• Pt names for Core Survey Data Tool

• Detail data on avr wt, fluid removed, etc..

QMAT: Readmissions Summary:

Filter Clinics, months

QMAT: Readmissions Detail- Alphabetical

List pts readmitted after d/c for 6 months,

diagnosis, LOS, etc..

Incorporate the Data into

QAPI and Core Survey Data

Tools

QAPI Measures: QIP

QAPI Core Survey Measures:

In-Center HD

QAPI Process: Using Outliers in Data to

Individualize QAPI to Patient

Network QIA- Smartsheet LTC tracking

Network QIA- Home Training Patient Tracker

QAPI Meetings

• Invite patient: Patient Ambassador

• Review data overview

• Focus on quality areas that need improvement

• Patient stays for 30 min- then discuss individual pts out of goal

ranges + plans to address

• Focus on Network QIAs- status, action plans

Communication to Staff

• Staff emgagement in QAPI critical to success

• Involve Staff in QAPI Meetings- techs, RNs, dietitians, social workers

• Communicate QAPI goals and areas of struggle to staff

• Huddles

• Seek Feedback from staff + involve staff in plans

• Make PI interesting or fun- eg. contest- LTC reduction

Nephrologist Review for

Medical Staff (OPPE)

Summary

• QAPI Process- Data Collection for QAPI, Core Survey Readiness

• Automating Data Collection- spend less time Data Mining, and

more time working with QAPI team on solutions for facility and

individual patients

• Good QAPI Process-> improve care for facility, and improve care

for individual patients

• Involve patients and staff

“If at first you don't succeed,

skydiving is not for you.”

Steven Wright

Email: dhenner@bhs1.org

Questions?