2011-2012 Goal Statement

All Network 3 facilities will:

  • Improve the quality and safety of dialysis related services provided for individuals with ESRD by:

      Hemodialysis Indicator

      Goal

      Hgb 10-12g/dL

      ≥ 71%

      Annual Hgb >12 g/dL reduction (ESA only)

      ≥   2%

      URR ≥65%

      ≥  93%

      Albumin ≥ 4.0/3.7g/dL(BCG/BCP)

      ≥ 36%

      TSAT ≥ 20%

      ≥ 88%

      Phosphorus ≥7mg/dL

      ≤ 10%

      Phosphorus < 5.5 mg/dL

      ≥ 67%

      Fistula rate prevalent patients

      ≥ 66%

      Fistula rate incident patients

      ≥ 50%

      Catheters >90 days

      ≤ 10%
    • Assigning specific staff who have the responsibility for home designee, transplant designee and vascular access coordinator functions
       
    • Maintaining expected levels of performance in national clinical performance indicators:
       
    • Ensuring ≥90% of patients will have a PTH measured at least every 3 months. The MRB strongly recommends that each facility should decide upon a desired range for PTH for the dialysis patient receiving care in that facility. At the current time the MRB cannot recommend specific parameters for PTH.
       
    • Ensuring ≥90% of patients will have a corrected calcium level measured at least every month. The MRB cannot recommend at this time a goal or threshold for corrected calcium concentration but recommends the target range of 8.4 -10.2mg/dL. The facility fistula goal is based on the following formula: (66%) – (facility baseline percent [AVF rate March]) x20%. This formula applies to all facilities whose March AVF rate is less than 65%. The improvement goal set for each facility with an AVF rate ≥ 66% will be at least 1%.
       
    • Monitoring and evaluating iron status through regular measurement of transferrin saturation (TSAT) and Ferritin Maintaining and follow a policy for administration of supplemental iron based on the K/DOQI guidelines
       

    • Peritoneal Dialysis Indicator

      Maintain Hgb between 10-12g/dL

      Maintain Albumin ≥ 4.0/3.7g/dL(BCG/BCP)

      Maintain TSAT ≥ 20%

      Decrease percentage of patients with Phosphorus ≥7mg/dL

      Maintain Phosphorus < 5.5 mg/dL

      Measure adequacy at least every 4 months

      Perform Peritoneal Equilibration Test within first 3 months of therapy and when indicated
      Ensuring 100% of patients have stenosis monitoring performed based on the guidelines established by K/DOQI
       
    • Ensuring 100% of frequent hemodialysis patients (≥ 4 times per week) will have a weekly Kt/V measured monthly. The MRB cannot recommend at this time a goal or threshold for weekly Kt/V but recommends the target of ≥ 2.0.
       
    • 100% of PD facilities will track and trend the monthly peritonitis and exit site infection rates and include the percentage of negative results.
       
    • Prescribed dose of PD should be altered as needed to maximize clearance, especially if patient appears to have uremic signs and symptoms.
       
       
  • Improve the independence, quality of life, and rehabilitation(to the extent possible) of individuals with ESRD through transplantation, use of self-care modalities, as medically appropriate, through the end of life by:
    • Encouraging the participation of patients in vocational rehabilitation programs
       
    • Posting in prominent place posters provided by QIRN3 describing treatment modalities and the Patient Rights and Responsibilities statement
       
    • Providing treatment schedules that allow patients to work or refer to another facility with this ability
       
    • Providing vaccinations for Influenza, Hepatitis B and Pneumonia according to the recommendations of the Centers for Disease Control and Prevention
       
    • Evaluating patients for transplant candidacy or referral within 6 months of initiating dialysis as evidenced by documentation in the medical record
       
    • Discussing advance care planning with patients within 6 months of intitiating dialysis 
       
       
  • Improve patient perception of care and experience of care and resolve patient complaints and grievances by:
    • Encouraging the use of those treatment settings most compatible with the successful rehabilitation of the patient
       
    • Implementing procedures for evaluating and resolving patient grievances
       
    • Fully documenting all involuntary discharges and notifying QIRN3 of each occurrence
       
       
  • Improve collaboration to ensure achievement of goals through the most efficient and effective means possible by:
    • Supporting the mission and activities of the Patient Advisory Committee
       
    • Developing partnerships with State and Federal agencies including the Office of Emergency Management
       
    • Encouraging staff participation in educational programs and national certification
       
    • Actively participating in the New Jersey Renal Coalition, Network Council and the CDC Hemodialysis Collaborative Monitoring forms submission and maintaining the required timeliness and accuracy rates of 90%

      MRB/BOD Approved: 5/2011