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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
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