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Quality ImprovementMISSION STATEMENT: "Our goal is to form a dynamic partnership designed to foster an environment of continuous quality improvement and mentoring in ESRD Network 13 facilities. TOGETHER, we will be our best and do our best in the interest of quality patient care." The information provided in this section is to help assist the dialysis and transplant providers to give the best possible care. All documents in this section are printer friendly for your convenience, so please feel free to copy the information as needed. The information provided in this section is to help assist the dialysis and transplant providers to give the best possible care. All documents in this section are printer friendly for your convenience, so please feel free to copy the information as needed.
Clinical Tools GFR CALCULATOR FOR CHILDREN AND ADOLESCENTS UP TO 18 YEARS OLD
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| Category of Care | Clinical Performance Measures (Examples) |
| Adequacy of Dialysis: Hemodialysis & Peritoneal Dialysis |
Pre and Post BUN Levels Utilized Dialyzer (HD) Prescription (PD) Delivered time on hemodialysis Pre and Post Patient Weights Times per week dialyzed (HD) Delivered time on dialysis (HD) Delivered BFR @ 60 minutes (HD) URR and/or Kt/V Kt/V Methodology |
| Anemia
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Hemoglobins |
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Vascular Access (HD)
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Type of access in use for study timeframe Reason for catheter, if applicable Catheter used for > 90 days Routine stenosis screening? Methods of access monitoring Type of access in use for first hemodialysis Date access placed Type of access in use after 90 days |
Nutrition |
Albumin Levels Lab method utilized for obtaining albumins |
Facility abstraction is done on selected patient records for the clinical performance measures for the specified time period . The patient sample is a random selection, via CMS, of patients who were on incenter hemodialysis or peritoneal dialysis during the last quarter of the year.
Each April, the Network forwards CPM data collection forms and instructions, patient sample, and fax response sheet to each facility selected to participate. Each facility abstracts data from patient records and submits forms to the Network office. Each fall, the Network QI staff performs a Data Validation Study (DVS) for the CPM activity. A random patient/facility sample is selected by CMS and then the Network requests patient records be submitted to the Network office for Network data abstraction.
CMS and the Network then analyze performance measures which should be monitored or investigated for opportunities to improve outcomes of care.
CMS Web site - Clinical Performance Measures (CPM) Project - Measures and Data Collection
| Quality Improvement | Tools |
| Vascular Access (HD) |
1. AV Intervention 2. Fistula First 11 Concepts ToolKits |
| Vascular Access (HD) Stenosis Monitoring |
Arteriovenous Grafts (AVG’s) / Monitoring for Stenosis |
| Vascular Access (HD) Catheter Reduction |
Catheter Reduction Tool (Excel) |
| Vascular Access (HD) AVF Functionality |
AVF Functionality Tool (Excel) |
| Anemia Management | Anemia Management Worksheet ( Tools ) |
| Adequacy of Dialysis: Hemodialysis & Peritoneal Dialysis |
Adequacy Audit Tools (Excel) Instruction for Adequacy Audit Tools (PDF) |
| Nutrition |
Updated 6/12/2007