HYPERCALCEMIA ORIENTATION WEBINAR

FEBRUARY 14, 2017

2:00 PM CT

Glenda Harbert, RN, CNN, CPHQ, Executive Director

Kelly Shipley, RHIA, QI Director

Dany Anchia, RN, QI Coordinator

Aparna Biradar, MPH, QI Analyst

Lydia Omogah, Lydia Omogah, Lydia Omogah, Lydia Omogah, QI Specialist*QI Specialist*QI Specialist*QI Specialist*

Javoszia Sterling, BA, Outreach Coordinator

NETWORK STAFF

*denotes project lead

� Focus Facility selection

� Goals of HYPERCALCEMIAHYPERCALCEMIAHYPERCALCEMIAHYPERCALCEMIA QIAQIAQIAQIA

� Project timeline

� Project components

� Sustainability

� CMS Watch List

�Wrap up

OBJECTIVES

*Please utilize the chat window for questions*

Location of project materials:http://www.esrdnetwork.org/hypercalcemia

SELECTION PROCESS

All eligible ESRD Network 14 facilities

(N=588)

Top facilities by worst

hypercalcemia rates (N=15)

Total number of focus facilities

(N=10)

Baseline Data: Q1/Q2 2016 (January – June)

Network 14 Average: 0.90%

National Average: 0.80%

Focus Facility Average: 7.18% (4.44% - 10.90%)

PY 2019 SCORING AND PAYMENT

REDUCTION METHODOLOGY

PY 2019 SCORING AND PAYMENT

REDUCTION METHODOLOGY

Focus Facility Average: 7.18% (4.44% - 10.90%)

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

PROJECT TIMELINE

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

1.1 .1 .1 . Se lect the root causes for Se lect the root causes for Se lect the root causes for Se lect the root causes for

each pat ient (one per page)each pat ient (one per page)each pat ient (one per page)each pat ient (one per page)

� If not listed, specify

additional root cause(s) in

other option box

2.2 .2 .2 . Does the pat ient have a Does the pat ient have a Does the pat ient have a Does the pat ient have a

PTH>600PTH>600PTH>600PTH>600

3.3 .3 .3 . I s the pat ient taking a I s the pat ient taking a I s the pat ient taking a I s the pat ient taking a

ca lc imimet ic?calc imimet ic?calc imimet ic?calc imimet ic?

ROOT CAUSE ANALYSIS (RCA)

RCA Link: https://www.surveymonkey.com/r/qiprcahttps://www.surveymonkey.com/r/qiprcahttps://www.surveymonkey.com/r/qiprcahttps://www.surveymonkey.com/r/qiprca

1.1 .1 .1 . Use th is pat ient key whi le Use th is pat ient key whi le Use th is pat ient key whi le Use th is pat ient key whi le

complet ing the on l ine RCAcomplet ing the on l ine RCAcomplet ing the on l ine RCAcomplet ing the on l ine RCA

2.2 .2 .2 . L is t the pat ient for #1 that L is t the pat ient for #1 that L is t the pat ient for #1 that L is t the pat ient for #1 that

corresponds to pat ient #1 in corresponds to pat ient #1 in corresponds to pat ient #1 in corresponds to pat ient #1 in

the RCAthe RCAthe RCAthe RCA

3.3 .3 .3 . Fax form to NW, do not emai l .Fax form to NW, do not emai l .Fax form to NW, do not emai l .Fax form to NW, do not emai l .

ROOT CAUSE ANALYSIS (RCA)

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

PLAN DO STUDY ACT CYCLE

1.1 .1 .1 . P lanPlanPlanPlan ---- p lan the deta i ls o f the test and make predict ions about outcomesplan the deta i ls o f the test and make predict ions about outcomesplan the deta i ls o f the test and make predict ions about outcomesplan the deta i ls o f the test and make predict ions about outcomes

2.2 .2 .2 . DoDoDoDo ---- conduct the test and conduct the test and conduct the test and conduct the test and co l lect dataco l lect dataco l lect dataco l lect data

3.3 .3 .3 . S tudyStudyStudyStudy ---- compare the p redict ions to the resul ts o f the testscompare the p redict ions to the resul ts o f the testscompare the p redict ions to the resul ts o f the testscompare the p redict ions to the resul ts o f the tests

4 .4 .4 .4 . ActActActAct ---- take act ion based on the new knowledgetake act ion based on the new knowledgetake act ion based on the new knowledgetake act ion based on the new knowledge

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

PROJECT COMPONENTS

1.1 .1 .1 . Complete each month, Complete each month, Complete each month, Complete each month,

f i r s t one is due f i r s t one is due f i r s t one is due f i r s t one is due

3/31/173/31/173/31/173/31/17

2.2 .2 .2 . Enter the assumed Enter the assumed Enter the assumed Enter the assumed

cont inuing cause(s) cont inuing cause(s) cont inuing cause(s) cont inuing cause(s)

for hypercalcemiafor hypercalcemiafor hypercalcemiafor hypercalcemia

3.3 .3 .3 . Enter the lab va luesEnter the lab va luesEnter the lab va luesEnter the lab va lues

4.4 .4 .4 . Confi rm ent r y in CWConfi rm ent r y in CWConfi rm ent r y in CWConfi rm ent r y in CW

5.5 .5 .5 . Email form to NWEmail form to NWEmail form to NWEmail form to NW

PROJECT COMPONENTS

Monthly Feedback Survey1.1 .1 .1 . Complete monthly, due by last day o f the month, f i r st one is Complete monthly, due by last day o f the month, f i r st one is Complete monthly, due by last day o f the month, f i r st one is Complete monthly, due by last day o f the month, f i r st one is

due 3/31/17due 3/31/17due 3/31/17due 3/31/17

2.2 .2 .2 . Oppor tunity to l i s t any successes , bar r iers , o r chal lengesOppor tunity to l i s t any successes , bar r iers , o r chal lengesOppor tunity to l i s t any successes , bar r iers , o r chal lengesOppor tunity to l i s t any successes , bar r iers , o r chal lenges

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

FACILITY PATIENT

REPRESENTATIVE (FPR)

� Every dialysis in Texas should have a FPR who will act as a link between patients and the facility staff.

� Recommend 1 FPR for every shift

� Consider diversity and predominant and secondary languages spoken by patients

� Use Network FPR Toolkit to orient staff and patients to FPR role

� Responsibilities

� Assist facility

� Gather information and ideas from patients

� Distribute information to patients

� Share ideas from patients with facility staff

� Co-design strategies to improve the delivery of care and patient information

� Support Patient and Family Engagement activities, including QI activities

� Promote Patient and Family Centered Care

� http://esrdnetwork.org/patients-families/patient-

representatives/

FACILITY PATIENT

REPRESENTATIVE (FPR)

PATIENT ENGAGEMENT

Patient Experience Week

(4/24/17 – 4/28/17)

1.1 .1 .1 . Rev iew mot ivat ional in ter v iewing Rev iew mot ivat ional in ter v iewing Rev iew mot ivat ional in ter v iewing Rev iew mot ivat ional in ter v iewing

s t rategies w ith your Fac i l i ty Pat ient s t rategies w ith your Fac i l i ty Pat ient s t rategies w ith your Fac i l i ty Pat ient s t rategies w ith your Fac i l i ty Pat ient

Representat ive (FPR) Representat ive (FPR) Representat ive (FPR) Representat ive (FPR)

2 .2 .2 .2 . Determine best method to Determine best method to Determine best method to Determine best method to

communicate hypercalcemia communicate hypercalcemia communicate hypercalcemia communicate hypercalcemia

educat ion w ith pat ientseducat ion w ith pat ientseducat ion w ith pat ientseducat ion w ith pat ients

3 .3 .3 .3 . Implement that s t rategy w ith a Implement that s t rategy w ith a Implement that s t rategy w ith a Implement that s t rategy w ith a

pat ient w i th hypercalcemiapat ient w i th hypercalcemiapat ient w i th hypercalcemiapat ient w i th hypercalcemia

4.4 .4 .4 . Communicate those results to the NWCommunicate those results to the NWCommunicate those results to the NWCommunicate those results to the NW

PROJECT COMPONENTS

Root Cause Analysis (RCA)

Plan-Do-Study-Act

(PDSA) Cycle

Monthly Data

Collection Tool

Patient Engagement

Sustainability Plan

SUSTAINABILITY

� Sustain the improvements made during

the project after the project has ended

� Start early, at the beginning of the project

with the end goal in mind

� Use SUSTAIN mnemonic to remember the

seven steps of sustainability

� Complete and submit a Sustainability Plan

for each project to Network toward end of

project

� Role of organizational culture and

leadership in successful sustainability

activities

� Network 14 implemented a new method of follow up

beginning in 2016, continuing in 2017

� Facilities failing to submit required documents for projects

will receive:

� One written or emailed notice

� One notification via phone

� If no response received from facility, the facility will be placed

on the CMS Watch List, which will include:

� Report of non-compliance to corporate leaders (if applicable)

� Report of non-compliance with DSHS on monthly calls

� Report of non-compliance to CMS

CMS WATCH LIST

Location of project materials:http://www.esrdnetwork.org/hypercalcemia

THANK YOU FOR

PARTICIPATING

Lydia OmogahQuality Improvement Specialist

469-916-3802

lomogah@nw14.esrd.net

� Complete the Pre-Project Survey due 2/10/17

� https://www.surveymonkey.com/r/J872DCD

� Complete the Webinar Attestation Form due 2/17/17

� https://www.surveymonkey.com/r/B8W8XGZ

� Counts as your attendance to this webinar

� Complete the Root Cause Analysis Tool due 2/21/17

� https://www.surveymonkey.com/r/qiprca

� Submit the patient key used in conjunction with the RCA by fax

� Develop your Plan-Do-Study-Act (PDSA) due 2/24/17

� Schedule day/time with project lead to discuss

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