ESRD Network 17. Annual Report January 1, 2014 through December 31, Contract Number: HHSM NW017C

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1 ESRD Network 17 Annual Report 2014 January 1, 2014 through December 31, 2014 Contract Number: HHSM NW017C Presented to: Centers for Medicare & Medicaid Services The mission of Western Pacific Renal Network, LLC is to facilitate improvement of the quality of care provided to ESRD patients. Page 1 of 57

2 Table of Contents Executive Summary... 3 Introduction... 4 CMS End Stage Renal Disease (ESRD) Network Organization Program... 4 Medicare Coverage for Individuals with ESRD... 4 History of CMS ESRD Network Organization Program... 4 Western Pacific Renal Network s Role in Improving the Quality of... 5 ESRD Care... 5 Network Goals... 7 Profile of Patients in Western Pacific Renal Network s Service Area... 8 Improving Care for ESRD Patients Vascular Access Patient Safety Patient Safety: Support for the National Healthcare Safety Network (NHSN) Patient Safety: Healthcare-Acquired Infection Learning and Action Network (LAN) Patient Safety: Reducing Rates of Healthcare-Acquired Infections Support for the ESRD Quality Improvement Program (ESRD QIP) Provider Education Ensuring Data Quality Disparities in ESRD Care Partnerships and Coalitions Patient and Family Engagement Education for ESRD Patients and Caregivers Patient Engagement Learning and Action Network (LAN) Support for ICH CAHPS Grievances and Access to Care Grievances and Non-Grievance Access to Care Cases Referred to State Survey Agencies Recommendations for Sanctions Recommendations to CMS for Additional Facilities Emergency Preparedness and Response Data Tables Appendix. Network Staffing and Structure Network Boards and Committees Page 2 of 57

3 Executive Summary During the twelve months covered by this report, Intermountain End-Stage Renal Disease Network Inc. (ImESRDN), completed work as contracted with CMS as ESRD Network 17 (Western Pacific Renal Network, LLC) and performed all functions and completed all activities required by its contract (HHSM NW017C). The majority of Network 17 resources were dedicated to Quality Improvement, Patient Services and Data Collection activities in the Network Statement of Work. Quality Improvement projects continue to drive the Network s agenda with numerous resources dedicated to the new Patient Engagement Learning and Action Network activities, as well as work to resolve grievances, increase arteriovenous fistulas, decrease central venous catheters and decrease Healthcare Associated Infections. Through this calendar year, Network 17 has provided countless hours of technical assistance to the community it serves. Through its work on Patient and Family Engagement, the Network saw increases in the percentage of patients who demonstrated a greater understanding about their dialysis journey. The Network saw an increase of the number of arteriovenous fistulas (AVFs) used from 64.7% in 2013 to 65.3% at the conclusion of In addition to the increase in AVFs, the Network facilities have demonstrated a very slight decrease in the overall prevalence of Central Venous Catheters from % in 2013 to 13.3% in This increase in AVFs and decrease in CVCs represents not only an improvement in the quality of care to beneficiaries, but a cost savings to the Medicare Trust. Service to the ESRD Medicare beneficiary population continued to be a major focus of Network 17 in The Network staff, in coordination with the Patient Leadership Committee and the Network Boards, provided educational resources, assistance with grievances, technical assistance and support to both beneficiaries and providers. Throughout the course of the year, the Network provided 21educational resources to patients within the Network s geographic area. Network 17 has actively assisted CMS in the full implementation of its web-based patient reporting tool, CROWNWeb. Network staff provided educational sessions, technical support, encouragement and assistance to its providers through the year. Network staff also provided numerous hours of technical support for facilities as they navigate the CDC s National Healthcare Safety Network. Page 3 of 57

4 Introduction CMS End Stage Renal Disease (ESRD) Network Organization Program The End Stage Renal Disease Network Organization Program (ESRD Network Program) is a national quality improvement program funded by the Centers for Medicare & Medicaid Services (CMS). CMS is a federal agency, part of the U.S. Department of Health and Human Services. CMS defines end stage renal disease (ESRD) as permanent kidney failure in an individual who requires dialysis or kidney transplantation to sustain life. Under contract with CMS, 18 ESRD Network Organizations, or ESRD Networks, carry out a range of activities to improve the quality of care for individuals with ESRD. The 18 ESRD Networks serve the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, American Samoa, Guam, and the Northern Mariana Islands. Medicare Coverage for Individuals with ESRD Medicare coverage was extended to most ESRD patients in the U.S. under the Social Security Act Amendments of 1972 (Public Law ). Individuals with irreversible kidney failure are eligible for Medicare if they need regular dialysis or have had a kidney transplant and they meet (or their spouse or parent meets) certain work history requirements under the Social Security program, the railroad retirement system, or federal employment. History of CMS ESRD Network Organization Program Following passage of the 1972 Amendments to the Social Security Act, in response to the need for effective coordination of ESRD care, hospitals and other health care facilities were organized into networks to enhance the delivery of services to people with ESRD. In 1978, Public Law modified the Social Security Act to allow for the coordination of dialysis and transplant services by linking dialysis facilities, transplant centers, hospitals, patients, physicians, nurses, social workers, and dietitians into Network Coordinating Councils, one for each of 32 administrative areas. In 1988, CMS consolidated the 32 jurisdictions into 18 geographic areas and awarded contracts to 18 ESRD Network Organizations, now commonly known as ESRD Networks. The ESRD Networks, under the terms of their contracts with CMS, are responsible for: supporting use of the most appropriate treatment modalities to maximize quality of care and quality of life; encouraging treatment providers to support patients vocational rehabilitation and employment; collecting, validating, and analyzing patient registry data; identifying providers that do not contribute to the achievement of Network goals; and conducting onsite reviews of ESRD providers as necessary. Page 4 of 57

5 Western Pacific Renal Network s Role in Improving the Quality of ESRD Care Western Pacific Renal Network, LLC (ESRD Network 17) is composed of the northern portion of the State of California, the State of Hawaii, the Island of Saipan (Commonwealth of the Northern Marianas Islands) and the United States Territories of Guam and American Samoa. The Network spans approximately 10,000 square miles which includes crossing the International Date Line to reach Guam and the Saipan and passing south of the Equator to American Samoa. From San Francisco one-way, the distance to: Hawaii is 2497 miles; American Samoa is 4942 miles and south of the equator; Guam is 5803 miles and Saipan 5710 miles respectively. California is ranked first in population, estimated state census 2013 was 38,332,521, and third in geographic area of the fifty United States. The Network 17 portion of the state is composed of the 45 most northern counties, starting in Fresno County and ending at the Oregon border, with Network 18 covering the southern 13 counties. Northern California includes about one-third of the state s population and about 60% of the land area. Hawaii currently ranks 40 th in population with an increase of 12.3% (1,404,054 Est. Census 2013) and 47 th in land area. The center of the population of Hawaii is located between the two islands of Oahu and Molokai. The population is very diverse, comprised of persons identifying themselves as Native Hawaiian, Asian, Caucasian, and Pacific Islanders. The average life expectancy of those born in Hawaii is longer than any other state in the nation. American Samoa is located in a group of volcanic islands, coral atolls, and has been a territory of the United States since April 17, The people of American Samoa are U.S. nationals, not U.S. citizens, but many have become naturalized American citizens. American Samoan ESRD patients are Medicare eligible and treatments are reimbursed by CMS accordingly. It is also worthy to note that mail is delivered to the post office only, as there are no street addresses. The population demographics remain largely unchanged with 95% of the populous living on the largest island, Tutuila. The language spoken by 90.6% of the people is Samoan (closely related to Hawaiian and other Polynesian languages), 2.9% English, 2.4% Tongan, with 2.1% of the people being bilingual. Guam is the largest and southernmost of the Marianas Archipelago, located in the Western Pacific Ocean. The natives of Guam are Chamorro. The Chamorro, Guam's indigenous people, first populated the island approximately 4,000 years ago. Guam crosses the International Dateline and is approximately 19 hours by air from San Francisco. The Island of Guam elected not to join the Commonwealth of the Northern Mariana Islands but as an organized, unincorporated Territory of the United States. The people have been United States citizens since It is one of five U.S. Territories with an established civilian government. ESRD patients living in Guam are Medicare eligible and treatments are reimbursed by CMS accordingly. Saipan is in the United States Commonwealth of the Northern Mariana Islands (CNMI) (Rota/Luta, Tinian), a chain of 15 tropical islands belonging to the Marianas Archipelago in the Western Pacific Ocean with a total area of sq. miles. The largest of these islands is Saipan, which has the only two dialysis facilities available. The natives are also referred to as Chamorro. Page 5 of 57

6 The island group was ruled successively by Spain, Germany, and Japan, and after World War II, the United States under a trusteeship. The population includes Chamorro and other Micronesians as well as a large number of guest workers from Asia. The CNMI joined the United States as a Commonwealth in November ESRD patients living on Saipan are Medicare eligible and treatments are reimbursed by CMS accordingly. Saipan crosses the International Dateline and is approximately 19 hours by air from San Francisco. As of December 31, 2014, there were 25,696 patients on chronic dialysis in Network 17 showing an increase of 4.4% from There were 281 Medicare-certified dialysis facilities, 6 renal transplant centers and 4 Veterans Affairs facilities within the Network boundaries. Table A. Dialysis Facilities and Transplant Centers in Western Pacific Renal Network s Service Area, as of December 31, 2014 Category Number Number of Dialysis Facilities in Western Pacific Renal Network s Service Area* 281 Number of Transplant Centers in Western Pacific Renal Network s Service Area* 6 Source of data: End Stage Renal Disease National Coordinating Center (ESRD NCC) report to ESRD Forum. *Counts of dialysis facilities and transplant centers may include a small number of facilities that closed during the calendar year but did not have a closing date recorded in CROWNWeb as of December 31, Table B. Number of Dialysis Facilities in Western Pacific Renal Network s Service Area and Number and Percent of Dialysis Facilities Offering Dialysis Shifts Starting after 5 PM, as of December 31, 2014 Category Number Percent Number of Dialysis Facilities in Western Pacific Renal Network s Service 281 Area* Dialysis Facilities in Western Pacific Renal Network s Service Area Offering 70 25% Dialysis Shifts Starting after 5 PM* Source of data for number of dialysis facilities: End Stage Renal Disease National Coordinating Center (ESRD NCC) report to ESRD Forum. Source of data for dialysis facilities offering dialysis shifts starting after 5 PM: NCC Gap Report Shifts after 5 PM. *Counts of dialysis facilities may include a small number of facilities that closed during the calendar year but did not have a closing date recorded in CROWNWeb as of December 31, Diabetes continues to be the primary diagnosis for both the incident and prevalent ESRD population in Network 17. There is also a regional variation of diabetics associated with the cultural composition. The Pacific Islands and Hawaii have demonstrated a much higher percentage of diabetes. Fifty percent of the dialysis population enters the ESRD treatment with a diagnosis of DM II. Diabetes in the Pacific Island Territories is epidemic. The World Health Organization declared one of the Territories first in the world for obesity in The Network continues to be committed to increasing the awareness and participating in the quality improvement of patients with diagnoses of ESRD and Diabetes. Page 6 of 57

7 The Network has many roles within its CMS Statement of Work. First and foremost is the role of educator for both patients and professionals in the area of quality improvement. In 2014, the Network completed projects focused on education of the incident dialysis patient in its Navigating project, diabetic foot care in the Happy Feet project, patient safety, vascular access, and infection prevention. The Network also acts as a convener, bringing together the community to advance quality care for patients undergoing renal replacement therapy. Through the Transplant Referral Population Innovation Project, the Network in coordination with transplant and dialysis providers, as well as patient volunteers developed a program which helped to increase transplant referral not only in the general population, but more so in the female population in the participating centers. The Network also acts as a negotiator, counselor, and change agent as Network staff work to help decrease difficult situations which occur between patients and facility staff members handling grievances, access to care, and facility concerns. Each of these roles and projects will be more fully described later in this report. Network Goals The Board of Directors (BOD) of Intermountain End-Stage Renal Disease Network (ImESRDN) reaffirmed the following goals for ESRD Network 17 for calendar year 2014: To facilitate optimal care to all ESRD patients, working in cooperation with facilities internal quality improvement programs and through the support of the CMS Health Care Quality Initiative Program (HCQIP): CMS definition of quality care under the HCQIP includes access to care, appropriateness of care, desired outcomes of care, and consumer satisfaction; To sustain the Network 17 administrative framework to optimally plan, implement, and evaluate Network responsibilities and goals and to complete all CMS contract requirements; To maintain a patient-specific medical information system based on the data set required by CMS and to meet and/or exceed all data reporting requirements of CMS; To support the CMS goal for the Network program of improving data reporting, reliability, and validity between ESRD providers/facilities, Networks, and CMS; To promote access to appropriate modalities, including self-care and transplantation; To promote patients knowledge of and involvement in their ESRD care, and to promote patients rehabilitation; To serve as a resource and clearinghouse for information to the renal community, including information on patterns, processes, and outcomes of care in order to aid in identifying opportunities for improvement as well as the results of both successful and unsuccessful improvement projects; To assist facilities in developing, implementing, and evaluating intervention strategies to improve patient care and outcomes; To facilitate resolution of patient grievances; To work collaboratively with other organizations to facilitate the improvement of care to ESRD patients; and To promote patient-centered care. These goals are approached through means that are patient-centered, safe, effective, efficient, equitable, and timely. It is expected that the outcomes will be measurable, using valid, evidence-based performance indicators; strategies are developed through broad consensus and Page 7 of 57

8 have strong correlation to patient outcomes. The Network embraces cultural change and process redesign. The Health Care Quality Improvement Program (HCQIP) for the ESRD Network Program mission supports achievement of the strategic goals by assuring the Institute of Medicine aims, as they relate to individuals with ESRD, ensure that care delivery is patient-centered, safe, effective, efficient, equitable, and timely. An integral portion of the Western Pacific Renal Network s Internal Quality Improvement (IQI) program is the ability to evaluate the success of the projects and activities undertaken as a part of the Statement of Work. This evaluation is completed through rapid-cycle, real-time analysis of the effectiveness and efficiency of its activities through continuous review and evaluation of all the Network 17 projects and activities. The evaluation process is completed in various ways, specific to the needs, scope and extent of the project being evaluated. Evaluation of Effectiveness In order to ensure that the Network continually makes progress toward meeting the CMS goals, the Network uses the following means to evaluate effectiveness. Evaluations have been done by formal feedback mechanisms (reports), through informal feedback (phone calls and consultation), Network staff review, MRB and BOD review, and through individual communication. The results of these evaluations have allowed the Network to be nimble and responsive to changes needed for improvement. Profile of Patients in Western Pacific Renal Network s Service Area The ESRD Network Program collects data on incident (new) ESRD patients, prevalent (currently treated) dialysis patients, and renal transplant recipients. Western Pacific Renal Network uses data on patients clinical characteristics including primary cause of ESRD, treatment modality, and vascular access type to focus its outreach and quality improvement activities. Table C. Clinical Characteristics of the ESRD Population in the Network Area, Calendar Year 2014 Category Number Percent Incident (New) ESRD Patients Number of Incident ESRD Patients, Calendar Year Primary Cause of ESRD among Incident ESRD Patients Diabetes % Glomerulonephritis 389 7% Secondary Glomerulonephritis/Vasculitis % Interstitial Nephritis/Pyelonephritis % Hypertension/Large Vessel Disease % Cystic/Hereditary/Congenital Diseases 168 3% Page 8 of 57

9 Neoplasms/Tumors % Miscellaneous Conditions 405 7% Not Specified 217 4% Prevalent Dialysis Patients Number of Prevalent Dialysis Patients as of December 31, Treatment Modality of Prevalent Dialysis Patients as of December 31, 2014 In-Center Hemodialysis or Peritoneal Dialysis % In-Home Hemodialysis or Peritoneal Dialysis % Vascular Access Type at Latest Treatment among Prevalent In-Center and In- Home Hemodialysis Patients as of December 31, 2014* Arteriovenous Fistula in Use % Arteriovenous Graft in Use % Catheter in Use for 90 Days or Longer % Renal Transplants Number of Renal Transplants, Calendar Year Transplant from Deceased Donor % Transplant from Living Related Donor % Transplant from Living Unrelated Donor % Donor Information Not Available 0 0% Mortality Number of Deaths of ESRD Patients, Calendar Year Source of data (except vascular access data): CROWNWeb Annual Report tables. Source of vascular access data: End Stage Renal Disease National Coordinating Center (ESRD NCC) Fistula First Catheter Last (FFCL) Dashboard. *Vascular access information reported in this table is based on facility-level data submitted to CMS. CMS has identified issues with data transmission and the application of vascular access data definitions and is correcting these errors by working directly with stakeholders and through the Networks. Page 9 of 57

10 Improving Care for ESRD Patients Western Pacific Renal Network works closely with ESRD patients, patients family members and friends, nephrologists, dialysis facilities and other healthcare organizations, ESRD advocacy organizations, and other ESRD stakeholders to improve the care for ESRD patients in Northern California, Hawaii, and the Pacific Territories of American Samoa, Guam and Saipan. Under contract with CMS, Western Pacific Renal Network is responsible for identifying opportunities for quality improvement and developing interventions to improve care for ESRD patients in Northern California, Hawaii, and the Pacific Territories of American Samoa, Guam and Saipan; identifying opportunities for improvement at the facility level and providing technical assistance to facilities as needed; promoting the use of best practices in clinical care for ESRD patients; encouraging use of all modalities of care, including home modalities and transplantation, as appropriate, to promote patient independence and improve clinical outcomes; promoting the coordination of care across treatment settings; and ensuring accurate and timely data collection, analysis, and reporting by facilities in accordance with national standards. Vascular Access Throughout calendar year 2014, the Network continued its work to improve prevalent AVF use rates and decrease long-term central venous catheter rates within Network 17 as a whole. The Network QI staff worked with individual facilities as well as groups of facilities to initiate facility-specific Quality Improvement Projects (QIPs), promoting the use of existing QI materials developed by the Networks and the Fistula First Breakthrough Initiative (FFBI) and to provide technical support. Through reporting from the NCC utilizing CROWNWeb data, the Network was provided with quarterly vascular access data in Quarterly data did not allow for rapid cycle improvement. Network 17 continued to have one of the highest prevalent arteriovenous fistula (AVF) rates and one of the lowest rates of Central Venous Catheters (CVCs) in the country throughout The Network worked with all providers to encourage AVF placement, as well as with a subset of dialysis providers demonstrating high CVC rates to encourage conversion to a permanent vascular access. At the close of 2014, the prevalent AVF in use rate was 64.7%. In 2014, the Network required 12 facilities to participate in an action plan project. This project required facilities with a CVC rate greater than 15% to submit its plan for improvement to the Network for review. The Network in turn reviewed all of the plans and worked directly with the facilities to implement their plans at the facility level. The Network provided technical assistance, resources, education, and support. At the close of 2014, the Network saw a decrease of its average CVC rate to 13.3%. The Network provided support to dialysis facilities for the submission of vascular access data into CROWNWeb. Batch data submission continues to be an issue in complete reporting of vascular access data; CMS is aware of this problem and continues to work with the batchsubmitting organizations to try to find a solution. Until this problem is solved, it is impossible for Networks to be held accountable for the submission of data for which they have no ability to affect. Page 10 of 57

11 Patient Safety Patient Safety: Support for the National Healthcare Safety Network (NHSN) In support of the QIP final rule requirements, the Network has supported new and returning facilities in the Network service area to successfully enroll in the NHSN database throughout In addition, the Network continues as a group administrator for the NHSN database system and has ensured that each facility within its geographic area has joined the Network s NHSN group which allows the Network staff to monitor data that is entered, look for potential problems with the data, and to assist facilities with their questions regarding this CDC database. The Network conducted monthly NHSN data checks using CDC created checklists to ensure quality reporting in the areas of: monthly census, vascular access counts, dialysis event and blood stream infection reporting. Each month the Network followed up with facilities with identified reporting errors. If the error was verified, education was provided to the facility and the error corrected. In May and September of 2014, the Network identified 20 facilities to participate in the Bi- Annual Survey; 10 with the highest blood stream infection (BSI) rates and 10 with the lowest BSI rates based on NHSN data. Using a CDC developed survey tool The Dialysis Event Surveillance Practices Survey the Network interviewed each facility to review infection control and surveillance practices, and to assess NHSN knowledge at the facility level. With each interview the Network took the opportunity to educate facility staff if applicable. In June, the Network followed up with those facilities to which education had been provided to assess sustainability. Patient Safety: Healthcare-Acquired Infection Learning and Action Network (LAN) A Learning and Action Network (LAN) is an ongoing collaboration among community partners representing a broad range of organizations and professions. Regularly scheduled LAN meetings provide an opportunity for members to share knowledge, skills, and resources to address an identified quality of care issue through collaborative problem solving. In 2014, Western Pacific Renal Network s PE\LAN focused on patient safety in dialysis facilities, with a specific focus on reducing rates of healthcare-associated infections (HAIs). The membership of the HAI LAN includes representatives from Network dialysis providers, the California Department of Health, Health Services Advisory Group (the Quality Improvement Organization responsible for California), patient volunteers, and Network staff. During 2014, Western Pacific Renal Network continued to work with Network 18 and the California QIO on HAI related activities. These activities are in support of the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination. Through the course of the year, the Network s held webinars highlighting various resources important in decreasing HAIs, including the CDC s tools for dialysis providers. Patient Safety: Reducing Rates of Healthcare-Acquired Infections The Network identified 51 facilities to participate in the CDC HAI QIA to Improve Patient Safety and Reduce Healthcare Associated Infections (HAI s). The facilities were asked to Page 11 of 57

12 complete 3 monthly audits, 30 hand hygiene observations, 10 catheter connection/disconnection observations and 10 fistula/graft cannulation observations using CDC audit tools. The objective of this activity was to increase familiarity with CDC-recommended practices, encourage habitual attention to and assessment of practices and identify and address barriers to recommended practices. Facilities were to focus on audit implementation putting the emphasis on correctly using the audit tool and less emphasis on the actual results of the audits. The Network assisted facilities with questions, providing assistance to those who did not meet the required audit numbers, and the collection of the monthly aggregate data from the facilities. The Network reported the aggregate data to CMS via the Dashboard Input Form. Support for the ESRD Quality Improvement Program (ESRD QIP) Network 17 provided educational resources to its staff, providers, and patients regarding the QIP throughout 2014, developing a User Guide for patients to better understand the QIP process and scoring. The User guide printed in English and Spanish provided patients with a simple way to understand and read the material. This education was provided by face-to-face education for Network staff to ensure that they are as fully knowledgeable as possible on the ESRD QIP measures, by electronic communication with Network facilities providing them with links to CMS resources and webinars, newsletters detailing the QIP components for each performance year, and written materials for patients explaining the QIP initiative and the provider certificate that they see in their individual facilities. Additionally, through the year, as updates to the QIP data are made available to providers for comment, the Network notifies the facilities in its service area that the information is available for review. Network staff provided technical assistance to facilities requesting help in quality improvement activities to improve their QIP scores. During each of the bi-monthly calls with the State Survey Agencies, Network staff provided updates on relevant QIP activities. Throughout the year, the Network assisted facilities in registering Master Account Holders (MAH) and notified CMS of any changes to the MAH quarterly. The Network notified its facilities of the requirement to post the facility s Performance Score Certificate (PSC) as directed by CMS, providing directions for accessing and printing the PSC. Provider Education Fostering Patient and Family Engagement at the Facility Level The Network developed a marketing plan, with the goal of getting providers of care in the renal community to work collaboratively with patients on adopting a set of behaviors that will help ensure that all ESRD patients have the opportunity and encouragement to fulfill their role in the practice of patient-centered care. The problem identified was that dialysis and transplant services have, for the most part become mechanical, impersonal with a majority of patients not participating in their care. Communication failures among providers exist at (multiple) critical points in patient care. A non-holistic approach to care is often taken. This involves treating the patient s primary diagnosis without considering the person as a whole. In order to reach the maximum number of facilities (on-site visits were limited by the Network s geography and travel budget limitations), the Network used available technology to its fullest in Page 12 of 57

13 order to spread the concepts related to patient and family engagement. The available distribution methods include: USPS mail, transmission, website postings, web-based learning, newsletters, in-person presentations, and fax transmissions. Types of materials include: hardcopy documents, videos, and audio recordings. In July of 2014 facilities that were identified for the grievance QIA were provided a workshop Dialyzing in Harmony to increase their knowledge and performance in the area of professionalism and communication. All five facilities were represented with several staff from each. In addition to the required facilities, several Best Practice facilities were present to share their successes with the group. The overall rating of the workshop by the attending facilities was excellent, but the most measurable level of effectiveness was measured by the fact the no additional grievance or occurrences happened in these facilities during the reminder of The Network staff provided CADPH with educational WebEx s on QIP, Involuntary discharge, Core Survey and any new developments. Joint calls were held in collaboration with Network 18 to utilize the time better. AVF workshops were help throughout the Network during 2014 particularly focusing on the action plan facilities. The success of the education is demonstrated by the increase in AVF rates and the decrease in CVC rates. The Network presented eight facility (six stateside/two Hawaii) based presentation on Handling Difficult Situations for facilities that has experienced patient/provider conflict. No further contacts concerning behavior on the part of the staff or patients occurred. A WebEx was provided to the 51 participating facilities at the beginning of the HAI/CDC Audit for infection control. This included education on hand hygiene, catheter connection/disconnection and AVF cannulation. Network 17 encouraged all facilities to participate in the audit as it may mandatory in 2016 in which case they will be prepared. Ensuring Data Quality Full implementation of the CROWNWeb software took place on June 14, Network 17 continued to work with dialysis facilities throughout 2014 to ensure that each facility has at least one authorized CROWNWeb user. While significant issues remain in the data being batched into CROWNWeb by both the Large Dialysis Organizations (LDOs) and the Health Information Exchange (HIE) developed by the National Renal Administrators Association (NRAA), the data appear to become more stable in Because of the very different nature of the data systems in use by the LDOs and HIE facilities and the reporting requirements of CMS, substantial manual intervention at the facility level in order to make the data conform to Medicare regulations continues. The Network is also aware that there are many missing clinical data points, especially in those data that are batched into CROWNWeb. This is concerning to the Network staff, since batching what is known to be false data into the CROWNWeb system in hopes that someone at the facility level corrects it, is problematic and may lead to corrupt and incorrect meta-data that organizations like USRDS and others use to detect trends and patterns in the ESRD population. The Network continued to work Page 13 of 57

14 with all of its facility representatives in an attempt to ensure that they understand the all of the elements of the CROWNWeb system throughout Disparities in ESRD Care In 2013, the Network began activities for a Population Health Innovation Pilot Project. Although originally scheduled to kick off at the beginning of 2013, due to a number of delays and data related issues, this beginning of this project was extended by CMS into the third quarter 2013 and continued into The project title was The Power of Choice Empowering the female dialysis patient to make appropriate choices in their care plan, namely in the area of transplant referral. The Network worked with participating dialysis facilities to empower staff to encourage the female dialysis patient to refer for transplant. The ultimate goal of the project was to impact the female disparity group of non-referrals for transplant and increase the referrals by 1%, achieve at least a 5% increase in referrals. With the assistance of the stakeholders and facilities, educational material was developed and placed in all facilities to encourage transplant referral for the female population. These informational resources were created in collaboration with patients for patients, bringing the patient s voice directly to the focused population. Network 17 focused on thirty facilities in Northern CA. These thirty facilities (>10% of the Network s facility count) had an aggregate patient population of 3,612 patients (>8% of the prevalent patients). Female patients represented 4.70% of the total number of patients reported to be on the aggregate facility census at the 30 selected facilities; 2.1% of patients who were referred to the four CA transplant facilities during the last six months of 2012 were female (transplant center data). Through personal communication with Nephrologists and Social Workers involved with the referral process with ESRD patients, the Network identified barriers in the transplant referral and evaluation process, in addition to examining the administrative process involving CROWNWeb for treatment options documentation, facility and medical group education, and the referral process. Barriers to transplant referral identified by providers included: transplant criteria, poor communications between partners (dialysis facilities and transplant facilities), the concern of the disparate group to be very caring of the family s (especially the children) well-being, concern over the transplant surgery, the thought that dialysis treatments are an acceptable option, age, and lack of someone to assist the female patient during recovery from transplant. The Network partnered with the five other ESRD Networks working on the Transplant Referral project to create a booklet containing patient stories about the transplant process. The Network provided four stories to the booklet from female patients on the Network s Patient Leadership Committee. These stories were sent out to each of the thirty participating facilities to share with their patients. Page 14 of 57

15 Aim 2 Disparities on Female Transplant Referral 5% Imprvmt 25% 20% 15% 10% 5% Imprvmt 5% 0% Baseline May June July August September ESRD Facilities and Providers Partnerships and Coalitions Developing and maintaining cooperative and constructive relationships with the facilities within the Network is the MRB s approach to its responsibilities for continuous quality improvement. The MRB's philosophy is to meet CMS mandates by implementing programs that provide both the Network and facilities with useful information about the ESRD care being delivered, programs that are least burdensome and most easily carried out within the existing practices of facilities, and those that maintain and improve, where possible, the quality of patient care. Network 17 provided educational opportunities for dialysis providers on the tools and techniques of CQI, as well as mentoring for individual QI projects was provided in various venues within Network 17. Please see prior sections of this report for project-specific descriptions and improvement results. Dissemination of clearinghouse information was accomplished in the following ways: Information that needed immediate dissemination to facilities was ed directly to the appropriate facility personnel Small news items that did not demand immediate dissemination were saved up and sent at one time in order to conserve resources The Network consistently utilizes to provide updates to its providers, including important recall/safety information, resources, updates, etc. Over the course of 2014, the Network provided a total of 12 continuing education hours to over 500 participants. ESRD Networks Network 17 is an active member of the Forum of ESRD Networks, contributing to Forum projects and participating in Forum activities. The Network Executive Director fills an ad-hoc Forum BOD position as the liaison to the Medical Advisory Committee (MAC) and was elected as the Forum Treasurer in July The Patient Leadership Committee Chairman is also part of the Forum Beneficiary Advisory Committee. Page 15 of 57

16 Network 17 staff members value the relationships that have been forged with other Networks staff members and utilize these relationships as valuable resources in Network activities. Network 17 distributes newsletters, project reports, and Network 17 created resources to other Networks. On an ongoing basis, Network 17 staff members provide consultation, technical assistance, or give actual Network 17 work products to members of other Networks who have contacted Network 17 seeking help with an issue or requesting a Network produced resource. The Executive Director interacts on a regular basis with other Network Executive Directors. This interaction allows for new ideas and sharing of successes and challenges. Network Coordinating Center (NCC) During 2014, the Network has assisted with the NCC s knowledge repository and data analysis functions by submitting data generated from its activities to the NCC as required by CMS. The Network has participated in the collection and dissemination of best practices and other forms of knowledge transfer that the NCC has made available to the Network organizations. The Network has focused its activities based on trends that it has detected and any trends that the NCC has made available to the Network organizations. State and Regional Office Survey Agencies In Network 17, the California Department of Public Health, CMS Region IX in San Francisco, and CMS Region X in Seattle provides program oversight for the Network 17 geographic area. Network 17 continues to maintain a very cooperative relationship with the state survey agencies in its geographic area along with the individuals in the state agencies and the regional offices who have frequent contact with Network staff. The ESRD technical expertise of the Network is always available to these agencies. The Network conducted bi-monthly calls with the State Agencies and Regional offices throughout Topics of interested were solicited from the participants and were added to the standing agenda for each call. The Network continued to use a standardized data form to share with the State Surveyors when they inquire about a facility in preparation for a Medicare survey of the facility which includes QI activities, vascular access statistics, complaints and grievance trends, and CROWNWeb users and participation. This form was revised in cooperation with State Agency representatives in 2014 to add in the elements which are necessary as part of the CMS Core Survey Process. Network 17 has developed and maintained a cooperative relationship with the federal government agencies that work with renal providers. These include the Survey and Certification Branch staffs of the San Francisco Regional Office. Cooperative activities during 2014 included reciprocal information sharing and joint problem solving including referral of a number of patient/family/other concerns that involved survey and certification issues to State Survey Agencies and received requests for information from the State Survey Agencies and several Network staff members collaborated with various State Survey Agency personnel regarding facility quality improvement issues following facility survey. The Network maintains a current list of contacts for each of the two Departments of Health (California & Hawaii) within Network 17. Page 16 of 57

17 Quality Improvement Organizations (QIOs) The Network continues to foster its relationship with the QIOs within its geographic area: the Health Services Advisory Group (HSAG) for Northern California, and Mountain-Pacific Quality Health Foundation in Hawaii and the Pacific Island Territories. The Renal Community Network 17 recognizes the importance of developing and maintaining cooperative relationships with the renal community in its area. Network 17 has made a determined and ongoing effort to coordinate its activities with other renal-related organizations and has participated in a variety of joint activities. Network 17 has worked with the National Kidney Foundation (NKF), the American Association of Kidney Patients (AAKP), the Medical Education Institute (MEI), and the Renal Support Network (RSN) to avoid duplication of service to patients in the Network area. Network 17 continued to work with the American Nephrology Nurses Association (ANNA) and the NKF to help provide annual educational opportunities for nephrology nurses and technicians, renal dietitians, renal social workers and nephrologists. The Network Director of Patient Services and the Patient Services Coordinators are members of the NKF Council of Nephrology Social Workers. The Network Director of Operations is a member of the American Nephrology Nurses Association (ANNA). Many members of the Network BOD and MRB are active in their local NKF affiliates. During 2014, Network 17 staff members attended national meetings of ANNA and NKF. Network 17 maintains a cooperative relationship with the following renal organizations that are active in its geographic area, including: San Francisco Chapter of the NKF CNSW Chapters in Northern California ANNA Chapters in Northern California Renal Support Network Southern California California Dialysis Council (CDC) Patient and Family Engagement Education for ESRD Patients and Caregivers Patient Engagement Learning and Action Network (LAN) Western Pacific Renal Network is committed to incorporating the perspective of patients, family members, and other caregivers into its quality improvement activities. In 2013, Western Pacific Renal Network established a Patient Engagement Learning and Action Network (PE/LAN). The Network 17 Patient Engagement Learning and Action Network (PE/LAN) re-convened in 2014 to promote patient-centered care and provide a foundation for spreading knowledge and best practices. The focus of the LAN was to and continues to enhance the patient s understanding as they begin the dialysis process. The Network recruited the SMEs Page 17 of 57

18 by outreach efforts to facility social workers as well as publicizing the volunteer opportunity directly to patients in the Network patient newsletter. In a December 2013 Patient Leadership Committee meeting the patient SMEs reviewed the results from the 2013 Quality Improvement Activity (QIA) and voted to continue the project, Navigating the Dialysis System, into the 2014 contract year focusing on another group of patients/facilities. Additionally, the patient SME volunteers decided on the two educational campaigns for 2014: Campaign #1; continuing the Network Awareness campaign from 2013 and Campaign #2; Guidelines for Heart Health. The PLC members reviewed the AIM statement used in 2013 and decided that it was still applicable to the project: By December 31 st, patients in facilities participating in the PE-LAN project will demonstrate a 5% relative improvement in their overall knowledge assessment scores, demonstrating their understanding of the components of Navigating the Dialysis System in the areas of fluid management, medication, diet, lab values, what dialysis does, and treatment options. The Change Package developed and tested in 2013 and continued in 2014, was a collection of interventions essential for achieving improvement objectives (the AIM). Items that are included in the Change Package for Navigating the Dialysis System are: a clear patient-focused description of the hemodialysis system for treatment, its importance to the patient, sample questions that the patient might ask during the initiation of treatment, and a notebook for the ongoing education process. Periodic learning sessions, both face-to-face and conference calls were held to allow reporting and sharing of implementation approaches and monitor progress toward the goals. The timing of the sessions took into consideration the needs of patients and other stakeholders. During the PLC/LAN meetings, all participants reviewed the LAN concept and processes. The concept of rapid cycle improvement was reinforced as we utilized the Plan-Do-Study-Act (PDSA) approach for improvement. The process begins with piloting a single new process, followed by examining results, and responding to what was learned by problem-solving and making adjustments, after which the next PDSA cycle would be initiated. Completing a series of small and rapid cycles to achieve the goals for the intervention was demonstrated to be effective in creating change. During the Action Periods, the participants focused on developing competencies, testing the Change Package, and suggesting modifications for the Change Package. The Network staff maximized interaction during the Action Periods through conference calls. During the calls, Network staff and LAN SMEs were encouraged to share outcomes, opportunities for improvement, challenges and barriers. The intended result of the LAN activities was to increase patient engagement and knowledge about the dialysis system as they begin their dialysis process. Based on discussions with the SMEs the measurement included a pre-test and post-test for the modules contained within the Page 18 of 57

19 patient educational resource book. The baseline data was collected in March 2014 and reported on the April 2014 Dashboard Input Form as directed by CMS. This effort augments the Centers for Medicare & Medicaid Services (CMS) Conditions for Coverage Subpart C, , Condition: Patient Rights. This Condition states that the patient has the right to receive all information in a way that he or she can understand, be informed about and participate in all aspects of his or her care, and to be informed about all treatment modalities and settings. Patient Engagement Learning & Action Network QIA LAN Navigating the Dialysis System 100% 80% 60% 40% 20% 0% Baseline May June July August September October Target milestones for the QIA LAN were developed in order to achieve the metrics which demonstrated a 5% relative improvement in at least 10% of the Network population. The goal for improvement was met by October 31, This project was very successful in The PLC recognized that the Navigating the Dialysis System should be shared nationwide with all patients and the PLC is currently looking for outside funding to make it possible to distribute to every patient. It is a perfect example of a conversation starter between patients and their Nephrologist. Patients who were interviewed in person by PLC members and Network staff pre-distribution all agreed that the information sent by CMS, as well as their perspective dialysis providers, was too much and got pushed aside. The amount was too overwhelming, the content was above their level of understanding or they were just too sick to care at the time the material was presented. The success of Navigating the Dialysis System for two years, provided the Patient LAN with the challenge of choosing a new project for Navigating will remain an internal project for the PLC and the Network with continued distribution when feasible. Page 19 of 57

20 2014 Patient Educational Campaigns Educational Campaign #1, 2014 Who We Are! This project consisted of numerous items which were shared with the facility to be given to patients. Each item identified the Network, provided the Network s contact information, and explained to the patients the Network s role, including the processing of grievances. A pre/post measurement tool was used to measure improvement. Target milestones for Campaign #1 were developed in order to achieve the metrics which reflected a 10% relative improvement in at least 20% of the Network population by the end of the fourth quarter The goal for improvement was met by October 31, % 80% 60% 40% 20% Percent of Patients Who Were Aware of the ESRD Network 0% Baseline May June July August September October Educational Campaign #2, 2014 Heart Health The second Educational Campaign that the PLC decided on based on their medical conditions, as well as currently available statistics on heart disease and diabetes in the ESRD population. The patients felt that heart disease plays a very important role in the care of the patient with ESRD and they wanted to increase awareness about Heart Health. A heart-shaped poster and guidebook were developed as educational tools. A pre/post measurement tool was used to measure improvement. Page 20 of 57

21 Target milestones for Campaign Two were developed in order to achieve the metrics which reflected a 10% relative improvement in at least 20% of the Network population by the end of the 4 th quarter The goal for improvement was met by October 31, % 80% 60% 40% 20% Percent of Patients Who Were Aware of Heart Health 0% Baseline May June July August September October Support for ICH CAHPS The Consumer Assessment of Healthcare Providers and Systems In-Center Hemodialysis Survey (ICH-CAHPS) annually measures the experiences of people receiving in-center hemodialysis care from Medicare-certified dialysis facilities. The survey measures were endorsed by the National Quality Forum (NQF) in Western Pacific Renal Network encourages qualified outpatient dialysis facilities to participate in the ICH CAPS data collection. The Network provided facility representatives with information regarding the ICH-CAHPS program and the requirements of CMS Quality Incentive Program relating to the administration of the ICH-CAHPS survey. Additionally, the Network provided information regarding the use of the ICH-CAHPS facility results for quality improvement and as a component of the facility s quality assessment performance improvement (QAPI) program. Additionally, monthly as directed in the SOW, the Network tracked administration of the ICH-CAHPS survey by the facilities in the Network area and reported the results on the monthly Dashboard Input Form. Grievances and Access to Care Western Pacific Renal Network responds to grievances filed by or on behalf of ESRD patients in Northern California, Hawaii and the Pacific Territories of American Samoa, Guam, and Saipan. In many instances, Western Pacific Renal Network works with individual facilities to identify and address difficulties in placing or maintaining patients in treatment. These access to care cases may come to the Network s attention in the form of a grievance, or may be initiated by facility staff. Page 21 of 57

22 Access to care cases include cases involving involuntary discharges, involuntary transfers, and failures to place. An involuntary discharge is a discharge initiated by the treating dialysis facility without the patient s agreement. An involuntary transfer occurs when the transferring facility temporarily or permanently closes due to a merger, or due to an emergency or disaster situation, or due to other circumstances, and the patient is dissatisfied with the transfer to another facility. A failure to place is defined as a situation in which no outpatient dialysis facility can be located that will accept an ESRD patient for routine dialysis treatment. In 2014, Western Pacific Renal Network responded to 63 grievances. Of these, one access to care grievance (2%) involved issues related to access to care. Network 17 responded to 68 additional non-grievance access to care cases brought to the Network s attention by facility staff. Table D. Grievances and Non-Grievance Access to Care Cases, Calendar Year 2014 Category Number Number of Grievance Cases Opened by Western Pacific Renal Network in Calendar Year 2014* 63 Number (Percent) of Grievance Cases Involving Access to Care 1 (2%) Number of Non-Grievance Access to Care Cases Opened by Western Pacific Renal Network in Calendar Year Total Number of Grievance and Non-Grievance Cases Involving Access to Care in Calendar Year Number of Cases Involving Involuntary Transfers** 7 Number of Cases Involving Involuntary Discharges** 44 Number of Cases Involving Failure to Place** 7 Source of data: Patient Contact Utility. *Includes grievance cases involving access to care. **Includes grievance cases involving access to care as well as non-grievance access to care cases. Grievances and Non-Grievance Access to Care Cases Referred to State Survey Agencies Month Grievance issue(s) State Outcome referred Substantiated, Unsubstantiated, or Unknown January IVD non payment CA Substantiated February Behavioral Agreement enacted by MD while patient still in hospital CA Unsubstantiated At risk for IVD Immediate Threat February mitigating circumstance of recent head injury CA Unknown May Patient Complaint: Intervention around an access failure CA Substantiated May Patient complaint: Unprofessional RN behavior CA Unknown June Patient complaint: Slow response to CA Substantiated Page 22 of 57

23 cramping, unprofessional RN behavior June IVD Immediate Threat CA Substantiated June Patient complaint: Inadequate access to clinic, poor parking arrangements CA Substantiated Patient complaint: Wrong Dialyzer August used on patient, patient s rights violation CA Substantiated Patient discharged from unit on 32 nd September day of missed treatments some of which were hospital days CA Unknown September Patient complaint: Ice machine removed CA Unsubstantiated Patient complaint: infection, September inadequate staff training in home hemodialysis CA Unsubstantiated October Patient complaint: Experienced retaliation for filing grievances CA Unsubstantiated October Patient complaint: Poor infection control practices CA Substantiated October Patient complaint: Poor infection October control practices CA Substantiated Confidential report of Poor dialyzer reuse practices CA Substantiated October Patient complaint: Infiltration CA Unsubstantiated October IVD Immediate Threat CA Substantiated November Anonymous call about reuse errors CA Unsubstantiated. November December Patient complaint: dialysis machine malfunctions CA Unsubstantiated Anonymous complaint: Staffing ratios CA Unknown Recommendations for Sanctions During 2014, Network 17 did not identify any providers as consistently failing to cooperate with Network goals and objectives. No sanctions against facilities or providers were recommended. Recommendations to CMS for Additional Facilities Network 17 made no specific recommendations to CMS Region IX or the DPH Offices in California or Hawaii for additional or alternative services during Home dialysis services were mapped and there does not appear to be any area that may be underserved. As has been stated in prior Annual Reports, the availability of a special purpose dialysis facility in one of more of the cities within Network s expansive geography would potentially provide a benefit to patients who require additional medical and/or mental health services above the level that can be Page 23 of 57

24 provided in a typical dialysis facility. Network 17 currently has 6 active transplant centers that include a pediatric transplant center. Emergency Preparedness and Response Western Pacific Renal Network maintains a multi-focal approach to internal and external emergency preparedness. Efficient and effective response to emergency and disaster events is optimized by advanced preparation and a clearly-defined process. Network 17 annually reviews the organization s disaster preparedness plan. This plan is an extension of the Business Continuity and Contingency Plan (BCCP) required by CMS and approved by the Network s Contracting Officer Representative (COR). The plan speaks directly to the Network function and how it works within the Network office. It can be completed in the case of a disaster and is revised annually and as needed. The plan also encourages individual employee preparedness for a disaster. Annually, the Network provides facilities with emergency preparedness resources, the role of the Network organization in community emergencies, and assists facilities connect with appropriate state emergency management contacts and resources. In case of disaster, such as a wildfire or earthquake, the Network has established an emergency contact cell phone for the facilities in the affected area to call the Network. The Network determines their operational status and reports the findings to the Network s COR per CMS direction. The Network 17 website contains a section on Emergency Preparedness for patients and professionals that is continuously updated. The Network provided emergency information to facilities throughout the year. The Network uses an electronic survey tool to assist facilities in reporting open/closed operational status and other data related to the current emergency which was found to be effective and efficient for both facilities and the Network. The Network 17 Outreach Coordinator organizes The Great California, Guam, Saipan, American Samoa and Hawaii Shakeout annually. Facilities are invited to participate in the table top review following the event for improvements. The Network also acts as a conduit to alert facilities of product warnings, recalls and safety updates from numerous sources, including CMS, FDA and product vendors. These alerts and warnings are transmitted to facilities electronically as they are available. Network 17 disaster preparedness involves a variety of potential disasters. In 2014 we experienced the following emergencies: 1. Wildfires in NorCal (39) 2. Earthquakes affecting three dialysis facilities in NorCal (1 - Mag 6.0) 3. Hurricanes in Hawaii (3) 4. Volcano Eruption in Hawaii (1) 5. Typhoons in Guam and Saipan (22 non-direct hit) In addition to organizational preparedness, Network 17 acts as a back-up Network for ESRD Network 15. Annually, the Network shares its emergency plan with Network 17 to ensure that its partner has the tools necessary to be prepared for an emergency. Page 24 of 57

25 List of Tables Table 1 ESRD Incidence Report Table 2 ESRD Dialysis Prevalence Report Table 3 Dialysis Patients Modality and Setting - In Home Report Table 4 Dialysis Patients Modality and Setting - In Center Report Table 5 All Renal Transplant Patients Report Table 6 Renal Transplant Recipient Report Table 7 Dialysis Death Report Table 8 Vocational Rehabilitation Report Page 25 of 57

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54 Appendix. Network Staffing and Structure The management staff of Western Pacific Renal Network consists of: Executive Director: Darlene J. Rodgers, BSN, RN, CNN, CPHQ, Position Summary: Under the general direction of the Intermountain End-Stage Renal Disease Network, Inc. /Western Pacific Renal Network, LLC Board of Directors; administers implements and evaluates the programs and activities of the Western Pacific Renal Network, in accordance with the CMS contract requirements. This individual splits her time between the Network #17 office in California and the Network #15 office in Denver, Colorado. Director of Operations: Allison Kregness, BSN, RN, CNN Position Summary: In cooperation with the Executive Director, as Director of Operations, this individual administers, implements and evaluates the programs and activities of Western Pacific Renal Network; serves as staff liaison for the Medical Review Board (MRB) and works with the MRB to develop, implement and evaluate Network programs for quality improvement as described by the Statement of Work and CMS s Health Care Quality Improvement Program (HCQIP) in accordance with the CMS contract requirements in the Novato, CA office. Quality Improvement Director: Gary Halick, MBA Position Summary: Under the general supervision of the Director of Operations the Director of Quality Improvement in the management the Network s quality improvement activities and provide technical support to the Network 17 nephrology community. In Page 54 of 57