Quality Improvement

Network 14 Projects/Facility Reporting Requirements Overview Document – Revised April 2011

2010 – 2011 Anemia Management Project

2009 – 2010 Phosphorous Management

2011 ESRD Network Facility Run Charts

The following run charts are using 2010 ESRD Network 14 data.

2010 Quality of Care Indicators Project

The ESRD Network of Texas, Inc. 2010 (2009 Data) Quality of Care Indicators Project is the continuation of a collaborative effort between the ESRD Network and the Texas dialysis community. Since 1996 the QIR facility specific charts has provided a unique opportunity for Texas dialysis facilities to compare core indicators and patient care processes to statewide averages. Whenever possible, national averages or clinical practice guideline recommendations are provided. Such review allows dialysis professionals to identify opportunities for improvement in their facility's processes of care.

Quality Improvement Tools

Dialysis Facility Specific Quality Management Program

Quality Assessment and Performance Improvement (QAPI) is a process of continually striving to improve. Whenever the Quality Management (QM)Committee notes that actual performance does not meet desired, QI activities should be initiated. The following are employed:

1. Identify specific needs for improvement.

    • This can be accomplished by comparing actual performance with desired performance (whether it is in the area of clinical outcomes, water quality, put on time, staff retention).
    • Many sources are available to describe desired performance; i.e., professional practice guidelines, national standards, as well as locally developed goals. Contact the Network QM staff if assistance is needed.

2. For each specific improvement project, establish a Quality Team consisting of 3-5 people who actually work in the process that is to be improved.

    • Give the team a clear charge as to what they are expected to accomplish along with an expected timeframe. Describe the desired change or outcome in one or two sentences.

3. Provide the resources, motivation, and training needed by the teams to identify causes, plan changes and then monitor for improvement.


4. The dialysis facility must develop, implement, maintain, & evaluate an effective, data-driven QAPI program with participation by the professional members of the Interdisciplinary Team (IDT).


5. Key elements of a comprehensive QAPI program include: Tracking, trending, analyzing, intervening, reassessing and continuous monitoring of all aspects of facility operations.“

Network 14 Comprehensive Facility Assessment Tool – December 2009

Network 14 Sample Resources for QAPI:

 

National ESRD Patient Safety Initiative

The National ESRD Patient Safety Initiative is a partnership between the Forum of ESRD Networks (Forum), the National Patient Safety Foundation (NPSF), and the Renal Physicians Association (RPA)

Comprehensive Interdisciplinary Patient Assessment Tool

Developed by the American Nephrology Nurses’ Association and the National Kidney Foundation, the Comprehensive Interdisciplinary Patient Assessment Tool was developed to meet the new condition (2008 Conditions for Coverage (CfCs) for End-Stage Renal Disease Facilities) requiring that a comprehensive interdisciplinary patient assessment be completed on all patients new to their facility.

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