Network of New England “An Educational Day &

Time Out For Technicians”April 24, 2008

Douglas Shemin, MD

Network Chairman

ESRD Network Organization• ESRD Medicare Program Public Law 92-603 in 1972.• Medicare coverage for ESRD began July 1973.• ESRD Network Coordinating Councils (32 areas)

established in 1978, consolidated to 18 networks in 1988.

• Network Organizations are independent contractors. Performance evaluated by CMS annually. 2/18 networks now administered by QIOs

• Contracts renewed every 3 years based on performance.• Network of New England, Inc. (not-for-profit

corporation) has held the ESRD Network contract for 30 years.

• New contract effective July 1, 2006 for three years.

ESRD Network Organization• Each network has paid staff, volunteer Board of

Directors (BOD), volunteer Medical Review Board (MRB). The MRB reviews, suggests QI projects, reviews grievances and complaints), and patient advisory committee.

• BOD and MRB made up of nephrologists, nurses, dieticians, social workers, administrators, transplant professionals, patient representatives and technicians.

• Network of New England welcomes interested renal professionals to our BOD and MRB.

What do the Networks do?

• Collect data (demographics, comorbidity, mortality information) on > 400,000 patients in > 4000 facilities

• Assess Data: Identify QI needs on a local level, institute and administer QI projects, offer assistance to underperforming facilities

• Respond to grievances, complaints, concerns by patients, families, and facilities.

• Special projects

New England Provider

Distribution

Number of ESRD Providers: 2001 & 2006 

 

   ESRD Resources in New England 12/31/2001

ESRD Resources in New England 12/31/2006

 

 

Modality By State: 2001 & 2006 

 

   2001 Dialysis Prevalence by Modality: Provider of Service

2006 Dialysis Prevalence by Modality: Provider of Service

 

 

Dialysis Patient Characteristics in New EnglandDialysis Population 12/31/2006

Age and Gender of the Dialysis Population

13%

32%

38%

18%13%

36% 34%

17%

0%

10%

20%

30%

40%

50%

60%

0-44 45-64 65-79 >= 80Age Groups

Pe

rce

nta

ge

of

Pa

tien

ts

Female Male

New England Population by Race

20%

4%

87%

8%

76%

5%

0%

20%

40%

60%

80%

100%

Black White Other

Dialysis Pts. All Residents

Etiology of Dialysis Population

41%

25%

15%19%

39%

22%13%

27%

40%

16%20% 23%

0%

10%

20%

30%

40%

50%

60%

Diabetic Hypertension Glomerulonephritis Other/Unknown

Black White Other

patients 18-54 Employed school

CT 3,389 962 277 23

MA 5,091 1,334 351 52

RI 880 208 45 5

VT 291 57 5 1

NH 731 194 53 4

ME 958 228 64 4

Total 11,340 2,983 795 89

From Network 1 Annual Report 2006: in New England, 27% working age dialysis patients work, 3% go to school

Providers with Treatments after 5PM2001 2006

# Dialysis

Providers# Providers w/ shift after 5PM

# Dialysis

Providers# Providers w/ shift after 5PM

CT 32 7 22% 31 9 29%

MA 67 26 39% 74 26 35%

ME 13 6 46% 18 5 28%

NH 10 6 60% 10 5 50%

RI 14 2 14% 18 2 11%

VT 6 4 80% 7 6 86%

Total 142 51 36% 158 53 34%

Dialysis Providers by Ownership12/31/2006

For profit chain

Hospital Independent,

nonprofit Total

CT 26 5 31

MA 51 23 74

ME 10 8 18

NH 9 1 10

RI 15 3 18

VT 0 7 7

Total 111 47 158

Percent 70% 30% 100%

   CMS / CPM Data

 Target

2006 National Report8,609

Patients

2007 National Report8,740

Patients

Network 2006

NationalReport

471 Patients

Network 2007

National Report

484 PatientsIndicator CMS Network

Mean URR % > 65 80% 90%* 88% 88% 90 % 91%

Mean KT/V > 1.2 84% 90%* 91% 90% 92 % 94%

Mean Hemoglobin > 11 gm/dL (Anemia)

80 % 80% 84% 84% 85 % 84%

Mean Tsat % > 20% 80% 80% 78% 80% 76 % 81%

Mean Serum Ferritin % > 100 ng/mL

80% 80% 95% 95% 96 % 95%

Prevalent Pts with Serum Albumin > 4.0/3.7 gm/dL BCG/BCP (Nutrition)

N/A 32% 33% 37% 32 % 35%

Prevalent Pts with Serum Albumin > 3.5/3.2 gm/dL BCG/BCP (Nutrition)

80% 80% 80% 82% 80 % 79%

Prevalent Pts with Catheter > 90 days (Vascular Access)

10%Reduce 3%/yr

21% 22% 20 % 20%

Prevalent Pts with AVF66% by

2009> 54.6% by

3/0844% 46% 51 % 57%

*Goals adjusted by the BOD/MRB 6/07. Source: CMS/CPM 2006/2007 report, which has 2005/2006 data.

+Serum Albumin is not considered a CPM. Note: Annual random 5% patient sample

4 targets: KT/V > 1.2, Hgb > 11, AVF, albumin > 4

• Rocco, Annals Internal Medicine, 2006

1 year death rate

4/4 targets 7 %

3/4 targets 14 %

2/4 targets 21 %

1/4 targets 25 %

0/4 targets 29 %

Why “Fistula First”?

Better solute clearance with AV FistulaeMuch lower risk of infection: Sixfold greater

rate of bacteremia with catheters (Hosp Inf Disease 2003)

Lower risk of death with AV Fistulae: (from CHOICE Study, JASN 2007)—47 % higher adjusted mortality rate in catheter patients compared to AVF patients

Prevalent Vascular Access Network # 1 and StateJan. 2007 to Jan. 2008

0

10

20

30

40

50

60

70

NW1 RI NH ME MA CT VT

2007 AVF 2008 AVF 2007 AVG

2008 AVG Catheter 2007 Catheter 2008

Quality Improvement Initiatives• Fistula First increase to 66% by 2009

• Clinical Performance Measures for focused intervention– Anemia Management

• Network Special QI Projects– Catheter reduction

– Nutrition management

– Patient Safety

• Facility Specific Quality Assessment and Performance Improvement Projects– Use data profiles to identify providers needing assistance

– Provide QI technical assistance to dialysis providers

5 Diamond Patient Safety Program

ESRD Network of New England(Network 1)

&

Mid-Atlantic Renal Coalition(Network 5)

Patient Safety Culture• Pervasive Commitment to Patient Safety• Open Communication• Blame-free Environment• Safety Design• Employee & Physician Involvement &

Accountability

Objectives• To promote patient safety values• To create an awareness of patient safety issues• To help dialysis units learn more about specific

areas of patient safety• To build a patient safety culture in every

dialysis unit

Educational Modules

• Hand Washing

• Flu Vaccination

• Slips, Trips and Falls

• Medication Reconciliation

• Emergency Preparedness

• Sharps Safety

• Decreasing Patient & Provider Conflict

Patient Safety Principles (required)

Under Development

• Staff Adherence to Procedures

• Dialyzer Set-up Errors

• Each topic is a complete educational module• Tools and resources are located on the Network

of New England website• Required and optional activities • PowerPoints for staff in-service presentations• Posters for display• Games and activities to engage patients

Modules

Recognition

All participants completing at least one component or more will be recognized

1 – 4 Diamonds

• Acknowledged in Network Newsletter

• Listed on Network Website

Recognition - 5 Diamond

• Acknowledged in Network Newsletter• Listed on Website• Special recognition at Annual Network Council

Meeting• 2 free passes to Annual Meeting• $75.00 gift certificate for entertainment material

for patients• Plaque to display in unit

Details• Time frame

– Starts April 2008 in Network #1 – Launch project at Technician Meeting

April 24, 2008– Mass Mailing to all Providers & Medical

Directors• Requires registration to do the program and

submission of documentation when each module is completed by dialysis provider

Promote

Please go back to your facility and encourage your management to participate in this educational safety effort.

• Promote patient, public, and professional education• Maintain a resource library of educational materials• Conduct workshops on quality of care concepts• Distribute a newsletter to dialysis and transplant facilities• Maintain Network website, with QI links• Establish partnership and collaborative activities• Major disaster coordination

• Assist patients, family or providers• Provide consultation or investigation

Complaints/Grievances

ESRD Community Information & Clearinghouse/Resource

Network Leadership: 3 Face to Face Meetings per Year

• Board of Directors: 25 to max of 40 members. Term of service is 2 years but can be renewed to a max of 4 years.

• Medical Review Board: 15 to max of 20 members. Term of service is 2 years but can be renewed to a max of 4 years.

• Election to be held in November 2007. Terms begin January 2008.

• 1/3 of BOD and MRB rotate off at each election cycle.

CMS Conditions of Coverage for ESRD Facilities Final Rule Published 4/15/08

Highlights of Provisions in the Final Rule Include:• Updated CDC guidelines for hemodialysis

facilities• Updated AAMI water quality guidelines• Defibrillators in every dialysis unit• Incorporates sections of the 2000 Life Safety Code

for fire safety• Option for patients to have an advance directive

Highlights of Provisions in the Final Rule Continued:

• Facilities provide written notice 30 days before a patient is involuntary discharged

• Facilities perform clinical assessment within 30 days, or 13 hemodialysis treatments, of patient starting treatment

• Home dialysis water purity requirements based on updated AAMI standards

• Facility-level quality assurance and performance improvement program

• Minimum qualifications and training requirements for patient care technicians (PCTs)

• Responsibility of Medical Director for Quality Assessment and Performance Improvement (QAPI) and involuntary transfers or discharges

• Electronic data collection and reporting

The CMS link to the final rule:www.cms.hhs.gov/CFCsAndCoPs/downloads/ESRDdisplayfinalrule.pdf

Highlights of Provisions in the Final Rule Continued:

Effective Dates

New Conditions for Coverage6 months

10/14/2008

Life Safety Code and Separate room for HBsAg+ patients

300 days

2/9/2009

Certification of technicians hired after 10/4/2008

18 months from hire

Certification of existing technicians24 months 4/15/2010

Governance: Electronic Data Submission

As of 2/1/2009, every facility must electronically submit data on all patients, including data on clinical performance measures, to CMS.

Thank you for all the good work you do for

your patients