2020 cms priorities, goals, and quality improvement activities · 2019-12-12 · 2020 cms...

2020 CMS Priorities, Goals, and Quality Improvement Activities

1

IPRO ESRD Network of New England (Network 1)Network Council Meeting

December 11, 2019

MeetingReminders

• This WebEx will be recorded and slides made available on the Network Website

• All phone lines have been muted to avoid background noise

• Be present and engaged in the presentations

• Be prepared for active participation in the WebEx chat board

p. 2

MeetingReminders

• Be prepared for active participation in polling questions

p. 3

AgendaTopics

• Overview of IPRO ESRD Program: Network 1

• National ESRD Initiatives

• Emergency Preparedness and Management

• Patient Experience of Care

• Patient Engagement

• Quality Improvement Activities (QIA)

• Information Management

• Closing Comments

p. 4

5

Overview of IPRO ESRD Program: Network 1

Danielle Daley, MBAExecutive Director

6

ESRDNetworks

7

IPRO ESRD Program

132,394ESRD Patients

1,948Dialysis Facilities

51Transplant Centers

Network 9IN, KY, OH

Network 6GA, NC, SC

Network 1CT, MA, ME, NH, RI, VT

Patients: 15,334Facilities: 201Transplant: 15

Network 2NY


Network 9OH, KY, IN


Network 6NC, SC, GA


NW2

NW1

IPRO ESRD Network ProgramNetwork Service Areas

MissionStatement

The Mission of the IPRO End Stage Renal Disease (ESRD) Network Program is to promote health care for all ESRD patients that is safe, effective, efficient, patient-centered, timely, and equitable.

p. 8

9 9

State ESRD Patient Census

# of Dialysis Facilities

# of Transplant Facilities

Connecticut 4,442 52 2

Maine 1,171 20 1

Massachusetts 7,074 84 9

New Hampshire 1,113 20 1

Rhode Island 1,168 17 1

Vermont 366 8 1

TOTAL 15,334 201 15Data Source: CROWNWeb 12/2019

Network Demographics By State

10 10

Ownership ESRD Patient Census

# of Dialysis Facilities

American Renal Associates 1,730 24DaVita 5,035 52Dialysis Clinic Inc. 753 9Diversified Specialty Institutes (DSI) 227 3Fresenius Medical Care 6,102 80Independent 1,334 28US Renal Care, Inc. 58 1Veterans Administration 95 4TOTAL 15,334 201Data Source: CROWNWeb 12/2019

Facility AffiliationBy Organization

Network 1Staff

Danielle R. Daley, MBAExecutive DirectorEmail: [email protected] Direct: (203) 285-1212

Agata Roszkowski, LMSWPatient Services DirectorEmail: [email protected] Direct: (203) 285-1213

Sarah Keehner, RN, BSN, CNNQuality Improvement DirectorEmail: [email protected] Direct: (203) 285-1214

Jaya Bhargava, PhD, CPHQRegional Operations DirectorEmail: [email protected]: (203) 285-1215

Cheryl Pettway Sr. Program Support CoordinatorEmail: [email protected] Direct: (203) 285-1222

TBDCommunity Outreach CoordinatorEmail: TBD Direct: (203) 285-1223

Nadine Caruthers, LPNQuality Improvement CoordinatorEmail: [email protected]: (203) 285-1224

Krystle GonzalezCustomer Service ManagerEmail: [email protected] Direct: (203) 285-1225

p. 11

CMS ExpectationsRole of the Network

• Improve quality of care for ESRD patients

• Provide assistance to ESRD patients and providers

• Encourage patient engagement

• Evaluate and resolve patient grievances

• Collect data to measure quality of care

• Support emergency preparedness and disaster response

p. 12

Technical AssistanceWe’re Here to Help

• The Network has tools to help with quality improvement activities–Infection prevention–Catheter reduction–Transplant referrals

• The Network provides technical assistance–Data reporting–Patient engagement–Access to care barriers

p. 13

–Benefits of home dialysis–Peer mentoring–Vocational rehabilitation

–Quality Incentive Program (QIP)–Patient/provider conflict–Patient safety

• The Network sponsors educational opportunities–Face-to-Face Meetings–Webinars–Conference Calls

• The Network shares data–Comparative Network, state, and facility level–Incidence, prevalent, and demographic statistics–Annual Report

p. 14

Technical AssistanceWe’re Here to Help

Are You Ready?

We’re More Than Just a Number

Let’s Test Your Memory

Do You Know Your

Network?

Polling Question

16

Emergency Preparedness and Management

Agata Roszkowski, LMSWPatient Services DirectorEmergency Management Coordinator

Emergency ManagementThings to Know

Facility Reporting/Tracking • Report Facility Status (Open/Closed/Altered)

• Report patient access to care

• Contact the Network to assist with local OEM coordination efforts

Prepare Patients for an Emergency• Be prepared patient worksheet

• 3-Day Emergency Diet

Prepare Your Facility for an Emergency• Technical assistance to facilities to develop

feasible, comprehensive emergency/disaster plansp. 17

Emergency PreparednessOverview

The Network 1 Emergency Preparedness and Management Plan Roles during an emergency Mobilization and response of the Network Providing and maintaining support Quality management of the emergency

p. 18

Are You Ready?FrequencyEmergency

Planning

We Want to Hear From

You

Polling Question

20

Patient Experience of Care

Agata Roszkowski, LMSWPatient Services Director

Patient Experience of CareGrievances Definition and the Network’s Role

• What is a grievance?

• Network’s Role–Facilitator–Expert Investigator–Educator–Quality Improvement Specialist–Advocate–Referral Source

p. 21

Patient Experience of CareGrievance Management and Best Practices

• Development/support robust grievance process

• Foster environment that encourages patients, family members, care partners to voice their opinions

• Encourage positive resolution focused outcomes

• Establish an anonymous grievance process

• Grievance Educational Materials–Network Grievance Poster –Forum Grievance Toolkit p. 22

CMS Expectations:Network Responsibilities

• The Network assists with patient grievances–Evaluate and resolve grievances using a patient centered approach –Follow CMS guidelines, document all Network steps of grievance

resolution, and adhere to timeframes –Perform quality of care reviews using an interdisciplinary approach

(LMSW / RN)–When necessary, refer cases to the Grievance Committee or Medical

Review Board for review

p. 23

CMS Expectations:Support for Access to Care Concerns

p. 24

Reasons for Access to Care Cases:• At-Risk of Involuntary Discharge

• Involuntary Discharge

• Involuntary Transfer

• Failure to Place

• Loss to Follow Up

Patient Experience of CareCommunity Resources

• Involuntary Discharge Resources–Threats are Not Okay Here Poster

–Involuntary Discharge Guide

• Grievance Management Process Resources

–Dialysis Patient Grievance Toolkit

• Communication Resources for staff and patients–Applying Net Forward Energy in Patient Care Webinar

–Relationship Centered Communication Webinar

p. 25

Are You Ready?ManagementDisruptive

Patient


You

Polling Question

27

Patient Engagement

Agata Roszkowski, LMSWPatient Services Director

Patient Advisory Committee (PAC)Structure and Function

• PAC members are :–Promote communication between patients and staff–Inform patients about the ESRD Network–Reach patients in the New England area

• PAC members are selected and nominated by facility staff

p. 28

Patient Advisory Committee (PAC)Patient Facility Representative

• Involved in the development of QIA interventions and resources

• Encouraged to participate in intervention implementation at the facility

• Patients are asked to:–Consider becoming a Peer Mentor–Share their ESRD journey story with others–Attend meetings led by the Network–Participate in national meetings and technical expert

panels

p. 29

Patient Engagement Goals

• Utilizing Peer to Peer model

• Increase self management behaviors

• Social support

• Health related quality of life and self-efficiency

p. 30

31

National ESRD Initiatives

Danielle Daley, MBAExecutive Director

ESRD Statement of WorkDecember 2019 - November 2020

Background & Purpose• To delineate tasks to be conducted by each End Stage Renal

Disease (ESRD) Network Organization contractor in support of achieving national quality improvement goals and statutory requirements as set forth in Section 1881 of the Social Security Act and the Omnibus Budget Reconciliation Act of 1986

• Tasks in this SOW are intended to align Network activities with:– Department of Health and Human Services (HHS) National

Quality Strategy (NQS)– HHS Secretary Priorities – Centers for Medicare & Medicaid Services (CMS) goals

p. 32


HHS Secretary’s Priorities1. Opioid Crisis

2. Health Insurance Reform

3. Drug Pricing

4. Value-Based Care

p. 33


CMS Goals1. Empower patients and doctors to make decisions about their

health care

2. Usher in a new era of state flexibility and local leadership

3. Support innovative approaches to improve quality, accessibility, and affordability

4. Improve the CMS customer experience

p. 34


Areas of Focus • Aligned with Executive Order for Advancing American Kidney Health

(AAKH)–Reduce the number of Americans developing ESRD by 25% by 2030–Doubling the number of kidneys available for transplant by 2030–80% of new ESRD patients in 2025 either receiving dialysis at home or

receiving a transplant

p. 35


Collaborations• National Coordinating Center (NCC)

• Kidney Community Emergency Response Program (KCER)

• State Survey Agencies

• National Accreditation Agencies

• Quality Innovation Networks (QIN-QIOs)

• Hospital Improvement Innovation Network (HIIN)

• Clinical Quality Improvement Contractors (CQICs)

p. 36

37

Quality Improvement Initiatives

ESRD Statement of WorkChanges

Changes to Quality Improvement Activates • There are Network wide goals

• No facility inclusion or exclusion criteria for any project

• All facilities are expected to participate in each activity

p. 38


National Coordinating Center (NCC) Learning and Action Network (LAN) Events • Bi-monthly webinars, hosted on the first three Tuesdays of a month from

3:00- 4:00 pm starting January • Recordings of the event will be available on the NCC website 10 business

days after the event • CMS Certification Number (CCN) are required at registration to get credit

for attending • 1 free continuing education credit for nurses and technicians available for

each call • 18 total CEs available

p. 39


Learning & Action Networks (LANs)• Patient Experience of Care

• Bloodstream Infections (BSI)

• Home Dialysis

• Patient and Family Engagement (PFE)

• Transplant

• Population Health Focused Pilot QIA (PHFPQ)

p. 40

ESRD Statement of WorkMonthly Communication

Monthly Data Collection Tool • Made available to facilities five business days prior to last day of

the month

• Due to Network on the last working day of each month

Provide Insider • Monthly newsletter that will be disseminated on the first Tuesday of

each month

• Contain links to education resources for QIAs, QIP, and webinar registration

p. 41

42

Making Care Safer by Reducing the Harm Caused in the Delivery of Care

Sarah Keehner, RN, BSN, CNNQuality Improvement Director

Reducing Harm When Delivering CareReduce Infections

Background• CMS has a goal to decrease the 2016 national infection rate 50%

by 2023

• Contains 5 sub-projects:–Bloodstream Infection Reduction–Long Term Catheter Reduction– Implementation of Center for Disease Control and Prevention Core

Intervention –Completion of the National Healthcare and Safety Network Annual Event

Surveillance Training – Improving process for communicating positive blood cultures between

hospitals and dialysis facilities

p. 43

Reducing Harm When Delivering CareReduce Rates of Bloodstream Infections

Objectives • To reduce the number of positive blood cultures reported in NHSN by 20%

across New England

Project Period• Baseline: January – June 2019

• Re-measurement: January – June 2020

Requirements• Utilization of CDC Core Interventions

• Conduct Root Cause Analysis (RCA)

• NHSN Annual Dialysis Event Surveillance Training p. 44

Reducing Harm When Delivering CareCore Intervention for BSI Prevention

p. 45

Are You Ready?UtilizationCDC Core

Interventions


You

Polling Question

Reducing Harm When Delivering CareLong Term Catheters Rate Reduction

Objective • To reduce the Network utilization rate of Long Term Catheters by 0.25%

Project Period• Baseline: July 2019

• Re-measurement: CROWNWeb data available in October 2020

Requirements• Use peer to peer to share experience with catheter related infections

• Improving the communication with vascular surgeons and interventional radiologist

• Improving surveillance of fistula and grafts p. 47

Reducing Harm When Delivering CareEnhancing Health Information Exchange

Objective • To enhance the process for communicating positive blood cultures

between hospitals and dialysis facilities

Requirements• The Network shall obtain documentation from the facility that use of the

HIE platform or other evidence-based highly effective information transfer system is successful. This may include policy and procedure or less formal evidence of a system.

p. 48

49

Promoting Modalities to Support AAKH

Nadine Caruthers, LPN Quality Improvement Coordinator

Promote Appropriate Home DialysisIncrease Rates of Patients in Home

Objective • To increase the Network home dialysis rate by 2.5%

Project Period• Baseline: October 2019 CROWNWeb Data

• Re-measurement: October 2020 CROWNWeb Data

Requirements• Encourage facilities to incorporate the seven steps leading to home dialysis

training into patient education, facility practice, and facility QAPI process

• NCC Home Dialysis LAN participation

p. 50

Promote Appropriate Home DialysisIncrease Rates of Patients in Home

Track and report to CMS the number of patients in each of the 7 steps each month:1. Patient interest in home dialysis2. Educational session to determine the patient’s preference of home

modality3. Patient suitability for home modality determined by a nephrologist

with expertise in home dialysis therapy4. Assessment for appropriate access placement5. Placement of appropriate access6. Patient accepted for home modality training7. Patient begins home modality training

p. 51

Promote Appropriate Home DialysisAvailable Resources

p. 52

Improve Transplant CoordinationIncrease Rates of Patients on Waitlist

Objective • Increase the number of patients on the kidney transplant waitlist by 1.25%

Project Period• Baseline is October 2019 UNOS Data

• Re-measurement: October 2020 UNOS Data

Requirements• Monitor/track patient progress through five steps leading to placement on

transplant waitlist

p. 53

Improve Transplant CoordinationIncrease Rates of Patients on Waitlist

Track and report to CMS the number of patients in each of the 5 steps each month:1. Patient interest in transplant2. Referral call to transplant center3. First visit to transplant center4. Transplant center work-up5. On waiting list or evaluate potential living donor

p. 54

Improve Transplant CoordinationAvailable Resources

p. 55

Are You Ready?

For Patients

Early Education


You

Polling Question

57

Quality Improvement Tools and Reporting

Sarah Keehner RN, BSN, CNNQuality Improvement Director

Quality Improvement Tools Root Cause Analysis and Plan-Do-Study-Act

RCA• Conduct a RCA to identify the barriers for each initiative

• Many ways to conduct an RCA• 5 Why’s • Fishbone

• If a facility’s dialysis organization already utilizes a RCA tool then that template many be used

PDSA• Utilize the PDSA cycle to test the processes initiated to overcome

barriers

p. 58

Quality Improvement ToolsPDSA Template

p. 59

Quality Improvement ToolsEmpathy Mapping

p. 60

61

Data Management

Jaya Bhargava, PhD, CPHQRegional Operations Director

CMS Expectations: Facility ResponsibilitiesESRD Data Collection Systems

• CMS Designated Data Collection Systems–CROWNWeb

http://mycrownweb.org/assets/crownweb-dm/dm_guidelines/–National Healthcare Safety Network (NHSN)

https://www.cdc.gov/nhsn/dialysis/event/index.html• ESRD Outcome Reports

–Quality Incentive Program -https://cportal.qualitynet.org/QNet/pgm_select.jspo Performance Score Reports and Certificates

–Dialysis Data - http://www.dialysisdata.orgo Dialysis Facility Reports and Dialysis Facility Compare

–In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAPHS) - https://ichcahps.org/o Third Party Vendor p. 62

CMS Expectations: Network ResponsibilitiesData Reporting Assistance

• Educate facilities to follow CMS Data Management Guidelines

• Inform providers of upcoming deadlines

• Streamlined process to inform facilities of missing data

• Working towards 100% patient level data submission compliance

– CROWNWeb– NHSN

p. 63

ESRD QIP

NHSN

CROWNWeb

CMS ExpectationsCROWNWeb Data Quality Goals

• CMS issued CROWNWeb Data Quality Goals

• Established key indicators and goals align with Data Management Guidelines

• Used to assess facility data submission and performance

p. 64

CROWNWeb Data Reports from Network• Review reports and submit missing data in CROWNWeb

• All data submissions are time sensitive but highest priority with immediate action required are for:

–Missing Clinical Data reports - clinical month closes and cannot be changed–Facility Personnel Report – ensures the most current contact information is

available for your facility

• Your Facility Staff receive reports in these areas on a regular basis.

NEVER send PHI or PII via email to the Network

p. 65

CROWNWeb Facility Personnel

p. 66

• Monthly your CROWNWeb Data contact receives report

• Review and ensure Facility Personnel in CROWNWeb is complete and accurate

67 67

Technical AssistanceKnowledge Base and Customer Portal

• Platform for resolving and tracking requests for data assistance from facilities in our region

• Review articles related to different support topics• http://help.esrd.ipro.org/support/home

• Submit a request for data assistance directly from the website or using Email address below

• [email protected]

• Submit ticket for One-on-One Technical Assistance:• Use of WebEx “Meet Now” method for real-time assistance

p. 67

REDCap• REDCap is a secure web application used for building and

managing online surveys

• REDCap is provisioned by IPRO via Amazon Web Services (AWS) GovCloud (HIPPA compliant)

• It is used to collect virtually any type of data.

• It can be used for surveys containing patient data.

• Automatic reminders are set up

• Act on the survey if a reminder is received.

p. 68

Are You Ready?Fresdesk

Customer Service

Support Portal


You

Polling Question

70

Closing Comments

CMS Expectations Facility Responsibilities

• Participate in Network Quality Improvement Activities (QIAs)

• Inform patients of available Network resources–Grievance resolution–Educational materials–Peer-to-peer mentoring

• Notify the Network of major events–Facility emergencies–Leadership changes

• Respond to inquiries and requests for information

p. 71

CMS ExpectationsFacility Responsibilities

• Timely submission of data

• Keep facility personnel information updated in CROWNWeb

• Discuss challenges/barriers

**Communicate with the Network**p. 72

ESRD Network of New England Websitehttp://network1.esrd.ipro.org

p. 73

IPRO ESRD Program Facebook Pagehttps://www.facebook.com/IPROESRDProgram

p. 74

ESRD Network of New England2020 Educational Opportunity

Home Modalities Learning Series • Spring 2020

• A Center Experience: The Impact of Transitional Start Unit• HHD: Adequacy, Prescriptions and Outcomes• Transitions in Care: A patient road map for transitioning prevalent from

In-Center to Home

Kidney Discard and High Kidney Donor Profile Index (KDPI) Webinar• Spring 2020

8th Annual ESRD New England Fall Conference• October 8, 2020

– Mohegan Sun, Uncasville, Connecticutp. 75

Action ItemsDuring the Month of December

• Conduct “Know Your Network” in-service with all dialysis facility staff

• Identify at least one patient and/or family member or caregiver to participate in facility and Network engagement activities

• Review facility personnel in CROWNWeb and update individual records accordingly

• Educate dialysis staff about the facility’s CMS Certification Number (CCN)

• Conduct Root Cause Analysis (RCA) to identify barriers to reaching successful outcomes regarding the 2020 initiatives for improving kidney health

p. 76

Presentation TemplateDraft for Review

April 6, 2017

p. 1

Corporate Headquarters1979 Marcus AvenueLake Success, NY 11042-1002

www.ipro.org

For more information:Danielle Daley, MBA Jaya Bhargava, PhD, CPHQExecutive Director Regional Operations Director(203) 285-1212 (203) [email protected] [email protected]

Sarah Keehner, RN, BSN, CNN Agata Roszkowski, LMSWQuality Improvement Director Patient Services Director(203) 285-1214 (203) [email protected] [email protected]

2020 cms priorities, goals, and quality improvement activities · 2019-12-12 · 2020 cms...

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