confidential and proprietary patient centered care and the triple aims beverly hoek, rn, cnn quality...

Confidential and Proprietary

Patient Centered Care and the

Triple Aims

Beverly Hoek, RN, CNN

Quality Improvement Director

March 14, 2013


NEEDLESS TRAGEDY OF BOY, 12, WHO DIED JUST THREE DAYS AFTER DOCTORS MISSED RAGING INFECTION FROM CUT TO ARM HE GOT PLAYING BASKETBALL

'It was this lack of care and communication which resulted in Rory’s death and what we and our daughter Kathleen will live with every day of our lives. We have been handed a life sentence.'


Quality Insights Renal Network 3

“ The Network”

18 Networks throughout the US Each State is assigned to a Network Contract through CMS 3 Year Contract QIRN3 - NJ, Puerto Rico and US Virgin Islands Began a new contract in January 2013


New Jersey ESRD Population 2002-2011

2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

2000

4000

6000

8000

10000

12000

14000

92929597 9729

1001810270

1061110863

1139011656

12208

# E

SR

D P

ati

ents


ESRD Patients by County Atlantic 463 Bergen 990 Burlington 559 Camden 808 Cape May 110 Cumberland 360 Essex 1704 Gloucester 317 Hudson 857 Hunterdon 48 Mercer 345

Middlesex 845 Monmouth 782 Morris 434 Ocean 668 Passaic 736 Salem 54 Somerset 158 Sussex 67 Union 791 Warren 82


New Jersey Dialysis Facilities 1990-2012

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0

20

40

60

80

100

120

140

160

No. Dialysis Facilities

No. Dialysis Facilities


1999-2002 2003-2006 2005-2008 2006-2009 2007- 2010 2008-20110

5

10

15

20

25

30

35

29.6

26.5

23.1 22.2 21.3 20.6

NJ % of Deaths Due to Sepsis in the ESRD Popu-lation

NJ Death Due to Sepsis

% o

f D

eath

s due t

o I

nfe

cti

ons

US 14%


1997-2000

1999-2002

2003-2006

2005-2008

2006-2009

2007- 2010

2008-2011

0.85

0.9

0.95

1

1.05

1.1

1.15

1.021.04

1

0.9600000000000010.980.9500000000000010.950000000000001

1.06

1.091.07 1.08

1.11.08 1.08

Standardized Mortality RatioNW and New Jersey

NJ SMRNW SMR

Years

SMR


Federal Regulation § 494.180

Condition – Governance– Standard Designating a CEO or administrator…who

exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to—• Staff appointments• Fiscal operations• The relationship with the ESRD Network


(i) Standard: Relationship with the ESRD Network The governing body receives and acts upon

recommendations of the ESRD Network. The dialysis facility must cooperate with the ESRD Network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in the ESRD network activities and pursue Network goals.


Sanctions

The Network has the authority to recommend to CMS that they (CMS) impose Sanctions

– Close the dialysis unit– Reduction in reimbursement– CMS will not pay for any new patients on Medicare


Triple Aims

I. Better Care for the Individual through Beneficiary and Family Centered Care

II. Better Health for the ESRD Population

III. Reduce Costs of ESRD Care by Improving Care


AIM I - Domains Patient and Family Engagement Patient Experience of Care Patient –Appropriate Access to In-Center

Dialysis Care Vascular Access Management Patient Safety: Healthcare-Acquired Infections

(HAIs)


AIM II - Domain

Population Health Innovation Pilot Project– Increase Hepatitis B (HBV), Influenza, and

Pneumococcal Vaccination Rates


AIM III- Domain

Support for the ESRD Quality Incentive Program (QIP) and Performance Improvement on QIP Measures

Support for Facility Data Submission to CROWNWeb, NHSN, and other CMS- Designated Data Collection System(s)


Patient Centered Care Questionnaire Yes No

1. Are patients invited to attend your Performance Improvement meetings?

2. Does your facility conduct any form of patient and/or family group meetings? (patient council, support group, new patient orientation group)

If Yes, please describe:

3. Do you routinely invite patients/families to your Governing Body meetings?

4. Do you routinely in invite patients/patient’s family to attend their Care Plan meeting?

5. Do you measure the percentage of patients who attend their Care Plan meetings?

If Yes, approximately what percentage of the patients attend their Care Plan meeting?

6. Do you have a written policy and procedure related to family participation in the patient’s care such as involvement in the development of the Plan of Care and cannulation?


AIM IDomain: Patient and Family Engagement

Foster patient and family engagement at the facility level

Involve patient/families in CMS meetings

Convene a Patient Engagement Learning and Action Network (LAN)

Domain: Patient Experience of Care

Evaluate and Resolve Grievance

Promote use of the ICH CAHPS survey

Address issues identified through data analysis


AIM IDomain: Patient Appropriate Access to In-Center Dialysis Care

Decrease involuntary discharges and involuntary transfers

Address patients at risk for IVD/IVT and failure to place

Generate monthly access to dialysis care reports

Domain: Vascular Access Management

Improve AVF rates in prevalent patients

Reduce catheter rates in prevalent patients

Support vascular access reporting

Spread best practices Provide technical support Recommend sanctions


AIM I

Domain: Patient Safety : Healthcare - Acquired Infections (HAIs)– Support NHSN– Establish HAI LAN– Reduce Rates of Dialysis Facility Events


AIM II

Population Health Innovation Pilot Project – Decrease Disparities– Increase Vaccinations– Improve Dialysis Care Coordination and Reduce

Hospital Utilization– Improve Transplant Coordination– Promote Home Dialysis – Improve Quality of Life


AIM IIIDomain: Support Data Submission CROWNWeb, NHSN

Domain: Support ESRD QIP Assist Facilities in

Understanding and Complying with QIP Processes and Requirements


AIM I

Foster patient and family engagement at the facility level

Involve patient/families in CMS meetings

Convene a Patient Engagement Learning and Action Network (LAN)

Questionnaire Distributed Today – eventually we will be measuring patient participation

Recruit a few patients willing to attend a meeting with CMS

Recruit patients and develop two campaigns and one

QIA


AIM I

Evaluate and Resolve Grievances

Promote use of the ICH CAHPS survey

Address issues identified through data analysis

Everything is now a grievance at the Network level

What are you doing with the aggregate scores?

What are you doing to improve your score each year?


AIM I

Decrease involuntary discharges and involuntary transfers

Address patients at risk for IVD/IVT and failure to place

Generate monthly access to dialysis care reports

Two categories now IVD and IVT

What can we do to identify these patients early on and prevent IVD from the beginning

Report IVD/IVTs to CMS


AIM I Improve AVF rates in

prevalent patients

Reduce catheter rates in prevalent patients

Currently we have no accurate data but we will be targeting the lower performing facilities

Reduce Catheters > 90 days- any facility with >10% may have focused intervention


WITH A CVC!

In June 2012, There Were

2,471 Dialysis Patients in New Jersey


AIM I

Support vascular access reporting

Spread best practices

Provide technical support

Recommend sanctions

CROWNWeb

Panel discussions at annual meeting

Go to hospitals with you Big push by CMS to

impose sanctions on recalcitrant facilities


AIM I

Support NHSN

Establish HAI LAN

Reduce Rates of Dialysis Facility Events

NW3 has been working on this for 2 years

HAI LAN established in Puerto Rico in March 2012.

Waiting to hear from CMS what actual indicator will be measured.


USRDS Vascular Access Infection Rates in NJ in 2011

Mean 1.72/100 Pt Months

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 1011061111161210.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Inf rates

NJ Dialysis Facilities

Infe

cti

on

s / 1

00 P

ati

en

t M

on

ths


Vascular Access Infection Rates in NJ 2012

NHSN Self Reported Data on all Patients


AIM IIIncrease Vaccinations– Patient Hepatitis B– Staff Flu– Patient Pneumonia

Working in Puerto Rico where they have the highest mortality rate related to Flu and Pneumonia in the USA.

Vaccination PR NJ VI PR NJ VI 2010 2011 Patient Pneumonia

13.5% 50.1% 51.0% 13.6% 57.5% 53.3%

Patient Hepatitis B

49.3% 67.5% 65.0% 53.9% 65.6% 57.3%

Patient Flu 40.4%

68.5%

80.0%

47.8%

73.6%

79.0%

Staff Flu 31.7%

46.5%

34.2%

26.0%

47.3%

25.9%

Staff Hep B 69.9%

74.2%

64.4%

69.6%

74.2%

50.7%


AIM III

Reduce costs…. Example: In Puerto Rico

in the last 12 months, the BSI was has decreased by 16.4%.

They reduced the use of antibiotics by 20%

Each BSI is estimated to cost about $20,000. So in the 4th quarter 2011 in PR, 35 facilities had 190 BSIs = $3,800,000. In the 4th qtr 2012 the same units saved $623,200


Questions?

Quality Insights Renal Network 3

109 South Main Street, Suite 21

Cranbury, NJ 08512

609-490-0310

confidential and proprietary patient centered care and the triple aims beverly hoek, rn, cnn quality...

Documents

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