Quality Improvement Overview

A primary goal of the ESRD Networks is to improve the quality of health care services provided to ESRD beneficiaries. Network 14 utilizes various strategies to achieve this goal, such as development and coordination of quality improvement projects, provision of data feedback reports, offer of technical assistance by Network 14 QI staff and Medical Review Board, and provision of educational opportunities and materials.

Areas in need of improvement in Network 14 are identified by:

  • CMS direction
  • Patient and facility communications
  • Various data collections and reports
  • State surveyor and QIO collaborations
  • Input from renal community and Network 14 boards

These areas may be addressed through general measures for all facilities, such as posting educational materials on the website, or by specific Network intervention with targeted facilities, practitioners or regions.

The CMS Conditions for Coverage require each facility to participate in the Network CQI activities, as well as establish their own Quality Assessment and Performance Improvement (QAPI) program to include, as described in the Interpretive Guidance:

  • Monitoring data/information
  • Prioritizing areas for improvement
  • Determining potential root causes
  • Developing, implementing, evaluating and revising plans that result in improvements in care

Quality of care issues to be addressed by facilities include, but are not limited to, dialysis adequacy, nutritional status, mineral metabolism and renal bone disease, anemia management, vascular access, medical injuries and identification of medical errors, hemodialysis reuse program (if applicable), patient satisfaction and grievances, and infection control issues.

Additional information and assistance with QAPI activities may be obtained by contacting the QI staff at the Network office.

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Goals for Clinical Performance Measures/Quality Indicators

Network 14 endorses the CMS Quality Incentive Program goals in lieu of setting additional Network-specific goals.

Payment year 2023 Achievement Thresholds, Medians, and Benchmarks

Measure Achievement Threshold (15th Percentile of National Performance)* Median (50th percentile of National Performance)* Benchmark (90th Percentile of National Performance)*
Kt/V Composite 94.33% 97.61% 99.42%
Standardized Fistula Rate 53.29% 64.36% 76.77%
Catheter Rate 18.35% 11.04% 4.69%
Hypercalcemia 1.54% 0.49% 0.0%*
NHSN Bloodstream Infection* 1.193 0.516 0*
Standardized Readmission Ratio* 1.268* 0.998* 0.692*
PPW 8.12%* 16.73%* 33.90%*
Standardized Hospitalization Ratio* 1.248* 0.967* 0.670*
ICH CAHPS Survey
Nephrologists’ Communication and Caring
58.20%
67.90%
79.15%
Quality of Dialysis Center Care and Operations 54.64%
63.08%
72.66%
Providing Information to Patients
74.49%
81.09%
87.80%
Overall Rating of Nephrologists
49.33%*
62.22%*
76.57%*
Overall Rating of Dialysis Center Staff
50.02%
63.37%
78.30%
Overall Rating of the Dialysis Facility
54.51%
69.04%
83.72%

*Note: Values marked with an asterisk (*) are also the final performance standards for those measures for PY 2022. In accordance with our longstanding policy, we are finalizing those numerical values for those measures for PY 2023 because they are higher standards than the PY 2023 numerical values for those measures.

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Quality Incentive Program Information

The ESRD QIP is designed to provide better care to patients with ESRD. CMS will pay your facility based on the care that it provides to you. It is possible that your facility will receive a payment reduction if it does not perform well enough. You will not be impacted financially by the ESRD QIP.

You can use the ESRD QIP to see how your facility’s performance under the ESRD QIP compares to the performance of facilities nationwide in the same program. CMS requires facilities to post certificates describing how they performed on the ESRD QIP. You can also find this information on Dialysis Facility Compare, available for free at Medicare.gov. You can ask your facility about its ESRD QIP scores, including its Total Performance Score. This information can be used as one tool among many when making choices about your care. It is important to note that the ESRD QIP is not the sole method for evaluating quality care at a facility; you should consider other factors as well.

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Patients Resources

Find the care you need to make it easier to find and understand information about doctors, hospitals, nursing homes, and other health care services. Now you can compare location, quality, and price information for health care providers.

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2020 Influenza Vaccination Campaign

Protect Yourself. Protect Your Loved Ones – Get Your Flu Shot Today!

Protect yourself and your loved ones this flu season! Getting a flu vaccine during 2020-2021 is more important than ever because of the ongoing COVID-19 pandemic. Flu vaccination is critical for healthcare providers and for ESRD patients who are considered high risk for Influenza, COVID-19, and other serious complications.

The ESRD Network of Texas (Network 14) is working to ensure that 85% of Network patients receive an influenza vaccination by December 31, 2020.

Network Project Lead:

Arlandra Taylor – Quality Improvement Coordinator

office (469) 916-3800, email arlandra.taylor@allianthealth.org

To access the 2020 Influenza Vaccination Campaign, please click HERE.

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Infection Prevention Catheter Reduction (IPCR QIA)

The BSI QIA is aimed at reducing bloodstream infection rates within those Network 14 facilities with the highest BSI rates. Improvement will be obtained by utilizing observation audits, CDC Core Interventions, and the facility selection of a patient engagement activity.

Network Project Lead
Maryam Alabood, Quality Improvement Specialist

office (469) 916-3803, email maryam.alabood@allianthealth.org

To access the IPCR website please click here.

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Reducing Hospitalizations QIA

In 2020, the ESRD Network of Texas has been directed by the Centers for Medicare and Medicaid Services (CMS) to collaborate with outpatient dialysis facilities within the state of Texas and to achieve a 1 percentage point decrease in the average rate of overall ESRD related hospitalizations.

Network Project Lead: 

Dany Anchia, BSN, RN, CDN – Quality Improvement Director

office (469) 916-3813, email Dany.Anchia@allianthealth.org

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Patient Engagement

The ESRD Network of Texas has been directed by the Centers for Medicare and Medicaid Services (CMS) to collaborate with ESRD providers and stakeholders within the state of Texas. The goal is to support facility efforts to increase patients, family and caregiver engagement at the facility level.

The Network shall ensure implementation of  interventions at the dialysis facility level that foster patient and family involvement in the areas of promoting better health for the ESRD population; BSI, transplant, and home dialysis.

Network Contact

EdNesha Smith, Patient Service Director

office (469) 916-3808, email ednesha.smith@allianthealth.org

To access the Patient Engagement page please click here. For quick access to Smartsheet surveys, educational material and other resources available please click here.

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2020 Modalities QIA (Home/Transplant)

The ESRD Network of Texas has been directed by the Centers for Medicare and Medicaid Services (CMS) to continue to work with ESRD providers and stakeholders in 2020. The goal is to support all the initiatives detailed in the Advancing American Kidney Health (AAKH) Executive Order signed on July 10, 2019. To support this initiative, the 2020 Modalities QIA aims at promoting early referral of patients to transplant and home modalities. The quantitative goal is to increase the rate of patients added to the transplant wait list by at least 1.25% AND to increase the rate of patients that begin training for a home modality by at least 2.5% based on the baseline rates from October 2019.

Network Project Lead: 
Arlandra Taylor – Quality Improvement Coordinator

office (469) 916-3800, email arlandra.taylor@allianthealth.org

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Disparities

Disparities emerge when there is a lack of equality amongst identifiable groups (i.e. Gender, race, ethnicity, socioeconomic status) preventing equality of treatment available for all persons looking for assistance.

The CMS Equity Plan for Improving Quality in Medicare  (CMS Equity Plan for Medicare) outlines CMS‘s path to help advance health equity by improving the quality of care provided to minority and other underserved Medicare beneficiaries. The framework for the plan consists of three interconnected domains: increasing understanding and awareness of disparities, creating and sharing solutions, and accelerating implementation of effective actions. Minority populations experience disparities in the health care quality they receive, even when they have the same insurance, socioeconomic status, and comorbidities as their non-minority counterparts. Click here  for more information on building an organizational response to health disparities.

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