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Welcome!

TRANSPLANT WAITLIST TRANSPLANT IMPROVEMENT

PROGRAM FOR SUCCESS (TIPS)

ORIENTATION WEBINAR

January 24, 2019 1:00 PM CT

Dany Anchia, BSN, RN, CDN

Clinical Quality Manager

PAC Subject Matter Experts

Juan Morales Laredo, TX

C.B. Bryant

Amarillo, TX

Tameria Bell Lancaster, TX

Nathaniel Kirby Galveston, TX

PATIENT ADVISORY COMMITTEE

Focus Facility selection

Goals of the project

Project components & requirements

Timeline

Sustainability & Disparities components

Network Watch List

Project Timeline

Attestation & Polling

OBJECTIVES

*Please utilize the chat window for questions*

NOTIFICATION LETTER

You should have received the

notification letter via email

Notification emailed on 1/08/2019

Facilities’ contacts on file (CW)

including administrators and

regional/corporate leadership

SELECTION PROCESS

Network 14 facilities eligible to

report for all of 2017

(n=675)

Include at least 30% of Network

Facilities

(n=203)

Facilities with

60 mo. trend <1.97%

Average Rate for all selected

fac. 0.70%

Total number of Focus Facilities in Project for 2019

(n=207)

Baseline Data: Received Dec 2019

UNOS Waitlist Rate 60 month Average trend

Focus Facilities 207

National Rate: 18.5% as of 2016

CMS Goal by 2023: 30%

Our Goal for this project: 2% increase

PROJECT MAJOR COMPONENTS

Monthly

6 steps &

QAPI

Patient Engagement

NCC Transplant

LANs

RCA

RCI

FPR

ROOT CAUSE ANALYSIS (RCA)

https://www.surveymonkey.com/r/PFJSQPW

FACILIT Y PATIENT

REPRESENTATIVE (FPR) AND PATIENT

CHAMPION

Every dialysis in Texas should have a FPR who will act as a

link between patients and the facility staf f.

Recommend 1 FPR for every shift

Consider diversity and predominant and secondary languages spoken by patients

Use Network FPR Toolkit (RADAR Tool) 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

FACILIT Y PATIENT

REPRESENTATIVE (FPR) TOOLKIT

https://www.esrdnetwork.org/patients-families/patient-representatives

TRANSPLANT 6 STEPS & QAPI

6 steps &

QAPI

Tracking 6 STEPS

• Complete one Transplant Navigation Tool for each patient:

• Tracking each step monthly

• Reporting # pts added to waitlist monthly via Survey Monkey

• Network-developed Survey Monkey reporting tool

• Goal: facilities will be able to report numbers through Survey

Monkey every month

CMS SOW: 6 steps leading to receiving a transplant:

1) Patient interest in transplant

2) Referral call to transplant center

3) First visit to transplant center

4) Transplant center work-up

5) Successful transplant candidate

6) On waiting list or evaluate potential living donor

Download at https://www.esrdnetwork.org/transplant-qia

6-STEPS MONTHLY REPORT

Due first week of the following month (i.e., Feb is reported during the first week of

March.

Utilize the 6-Step Transplant Navigation Tool

Reported via Survey Monkey https://www.surveymonkey.com/r/J57HLK7

QAPI/QA REQUIREMENTS

• Regular review of 6-Steps

• Plan of Action if patient(s) not progressing (PDSA)

• Document communication with TP Centers (especially for steps 3-6)

CMS Statement of Work (SOW):

• “Facilities in the Transplant QIA are to incorporate the process steps into patient

education, facility practice, and the facility QAPI process…”

• Promote communication between dialysis facilities, transplant centers, hospitals,

nephrologists and other healthcare providers to improve the rate of patients on the

transplant waitlist and report results monthly.

• Engaging hospitals, transplant centers, and nephrologists along with other

healthcare providers to educate patients at the earliest diagnosis of ESRD about

transplant and begin the process of successfully being on a transplant waitlist.

PROJECT COMPONENTS

Patient Engagement

PATIENT ENGAGEMENT

Facility’s Patient Clinic Committee members reviewing

materials and the Lead Patient Committee member (FPR and

one of our PAC members0 demonstrating teach back with the

clinic staf f.

TP QIA PATIENT ENGAGEMENT

National Recognition

Events

OPTION 1

Network’s Patient

Engagement Calendar

OPTION 2

Facility’s

Patient

Engagement

Plan

OPTION 3

Patient Engagement Activities will be promoted

through the

recognition and involvement of nationally

recognized patient

days.

World Kidney Day (March 14, 2019) Link

National Kidney Month (March)

Patient Experience Week (April 22- 26, 2019)

https://www.theberylinstitute.org/page/PXWEEK and

https://www.nursebuff.com/patient-experience-week/

National Donate Life (April) Link

National Transplant Day (September 8, 2019)

https://www.whatnationaldayisit.com/day/Transplant-

Week/

(Network 14 and CMS want to see strong participation of

facility patient representatives)

PATIENT ENGAGEMENT ACTIVITY

TP QIA PATIENT ENGAGEMENT

PE Activity: March 2018

Network Calendar Activity

Facility Planned Activity

PE Activity: Apri l 2018

Network Calendar Activity

Facility Planned Activity

PE Activity: June 2018

Network Calendar Activity

Facility Planned Activity

PE Activity: July 2018

Network Calendar Activity

Facility Planned Activity

For May and August do your own Transplant Patient

Engagement activity.

T

O

NT

Calendar Link

TP QIA PATIENT ENGAGEMENT

Facility’s

Patient

Engagement

Plan

OPTION 3 Existing patient

engagement plan at the

facility can be uti l ized

Specify activity to be

completed

Provide documentation of

all activities completed to

the Network (by fax or

email) DO NOT INCLUDE ANY

PATIENT PHI

Complete survey questions

around the plan’s

effectiveness and patient

level of engagement

Will be reviewed by the NW

and PAC SME for approval

PROJECT COMPONENTS

NCC Transplant

LAN

The ESRD NCC Transplant Learn ing and Act ion Network ( LAN) ca l ls have two primary purposes:

The first is to improve information communication across care settings, with emphasis on communication between transplant centers and dialysis centers caring for the same ESRD patients.

The second is to increase awareness of and ways to support the patient through the waitlist process.

Facility Responsibility

Attend the ESRD NCC Transplant LAN every other month

Share and implement identified interventions to

improve the TP waitlist rates from each LAN meeting with

patients, staff, physicians, and other stakeholders.

NCC ESRD LAN CALLS

SUSTAINABILITY &

DISPARITIES

Sustain the improvements made during

the project af ter the project has ended

Sta r t e a r l y, 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

Disparities

Identify, notify the Network, and

address as needed

Interventions are meant to drive results

Network monthly tracking will include analysis of

progress versus baseline data

Trending will be reviewed and if needed an RCI such

as PDSA may be necessary for your facility

It will need to be incorporated and reviewed in QAPI/QA

RAPID CYCLE IMPROVEMENT

(RCI)

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 Network Watch List, which will

include:

Report of non-compliance to corporate leaders

Report of non-compliance to DSHS as needed

Report of non-compliance to CMS

NETWORK WATCH LIST

TIMELINE

Task January

Febru

ary

Marc

h

AprilM

ayJu

neJu

lyAugu

st

Septem

ber

October

Novem

ber

Decem

ber

Check

Network: Notified Facilities via email 1/8

Intro Webinar (Attestation due 1/31) 1/24

Pre-project Survey by 1/21

Select two staff leads by 1/21

Facilities to notify leadership/corporate by 1/31

FPR /TP Patient Champion Recruitment by 2/1

Root Cause Analysis (RCA) by 1/21

Monthly 6-Steps (Via Survey Monkey on 1st

week of the following month) & Review During

QAPI

x x x x x x x x

Participate in ESRD NCC Transplant LAN calls 1/22 TBD TBD TBD TBD TBD

Patient Engagement Activities (i.e.,NW Calendar)

Collaboration and partnerships with other

stakeholders

Meet Goal of 2% waitlist increase by 7/31

Sustainability Plans Due to Network 9/2

Project Close 9/30

Site Visits as needed throughout project

Sustain

Can be scheduled at any time

Attend any scheduled Webinars

Ongoing

Ongoing

QIP MEASURES

QIP MEASURES

For resources and to learn more about the technical specifications for

ESRD QIP Measures go to the following link:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/ESRDQIP/061_TechnicalSpecifications.html

We will be adding

transplant resources

to our website through

the project

We will collaborate with

transplant centers to

provide educational

opportunities

Explore Transplant

partnership

Send us your resources

ADDITIONAL RESOURCES

FOR FACILITIES

57

IN A NUTSHELL

• Identify at least 30% of facilities with the lowest 60

months waitlist trends within Network area to

participate (1.97% or below)

• Include all ages and modalities

• Numerator: track and report number of patients

added to the waitlist monthly

• Baseline: 0.70% (based on 60 month trend)

• Ensure patient engagement

• Demonstrate at least a 2% point improvement

MAIN INTERVENTIONS

• Notify facilities and leadership • Webinars • Data tracking of 6 steps • Monthly reporting • Root Cause Analysis (RCA) • Rapid Cycle Improvement (RCI) activities (i.e., PDSAs) • NCC Transplant LAN Calls participation • Patient engagement (FPRs/PAC/Patient Champions) • Partnerships with transplant centers (i.e., Houston

Methodist) • Collaboration with other stakeholders (i.e., Explore

Transplant Program) • Site visits • Sustainability Plan

Complete the Pre-Project Survey

Was included in your project notification letter

Have two project lead associates (Main and Back -up)

Setup a process to ensure continuity and accountability

Recruit a Facility Patient Representative/Transplant patient

champion. If you already have one, inform them on how they

can assist with this project

All these materials will be available on our website under the

Transplant QIA section

Identify and address disparities as needed

COMPLETE THE WEBINAR ATTESTATION (link in chat during

l ive presentation)

NEXT STEPS

https://www.surveymonkey.com/r/QX7ZLMK

Location of project materials:

THANK YOU FOR

PARTICIPATING

Dany Anchia, BSN, RN, CDN

Clinical Quality Manager

469-916-3813

danchia@nw14.esrd.net

QUESTIONS?

Dany Anchia, BSN RN, CDN

Clinical Quality Manager 469-916-3813

danchia@nw14.esrd.net