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Fistula First: AV Fistula Maturation Project

Svetlana (Lana) Kacherova, QI Director

Lisle Mukai, QI Coordinator

ESRD Network 18

October 23, 2008

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Special Acknowledgement forSpecial Acknowledgement forContent Contributions:Content Contributions:FFBI Leadership GroupFFBI Leadership Group

RMS Lifeline, Inc.RMS Lifeline, Inc.DaVita, Inc.DaVita, Inc.

John White, RN, Manager, John White, RN, Manager, Outreach and EducationOutreach and Education

Laura AdamsLaura AdamsIrina Goykhman, RN, MBAIrina Goykhman, RN, MBA

Lynda K. Ball, RN, BSN, CNNLynda K. Ball, RN, BSN, CNNQI Director, ESRD Network 16QI Director, ESRD Network 16

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Fistula First Breakthrough Initiative Fistula First Breakthrough Initiative (FFBI) Partners(FFBI) Partners

Dialysis facilitiesDialysis facilities Dialysis patientsDialysis patients NephrologistsNephrologists SurgeonsSurgeons CMSCMS ESRD NetworksESRD Networks State Survey AgenciesState Survey Agencies QIOsQIOs And many more!And many more!

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““Fistula First” GOALFistula First” GOAL

Goal is to maximize autogenous AVF Goal is to maximize autogenous AVF construction & success rate…..construction & success rate…..

To achieve in the shorter term (2006) the initial To achieve in the shorter term (2006) the initial K/DOQI minimum benchmark of AVF use in K/DOQI minimum benchmark of AVF use in 40% of prevalent patients….40% of prevalent patients….

And in the long-term (2009), a 66% AVF rate in And in the long-term (2009), a 66% AVF rate in prevalent patientsprevalent patients

Additional Goal: Reduce Catheter Use!Additional Goal: Reduce Catheter Use!

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Fistula First Goals (AVF Rates)Fistula First Goals (AVF Rates)

CMS goal – 66% by June 30, 2009CMS goal – 66% by June 30, 2009 Yearly Network 18 goal – Yearly Network 18 goal – 55.1 %55.1 % by June by June

30, 200930, 2009 Yearly Network Stretch Goal – Yearly Network Stretch Goal – 56.0%56.0% by by

June 30, 2009June 30, 2009 August 2008 AVF rates: NW 18 – 53.7%August 2008 AVF rates: NW 18 – 53.7% US – 50.7%US – 50.7%

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Tools & Best Practices:Tools & Best Practices:Fistula First Change ConceptsFistula First Change Concepts

1.1. Routine CQI Review Routine CQI Review of vascular accessof vascular access

2.2. Timely referral to Timely referral to nephrologistnephrologist

3.3. Early referral to Early referral to surgeon for “AVF surgeon for “AVF Only”Only”

4.4. Surgeon SelectionSurgeon Selection5.5. Full range of Full range of

appropriate surgical appropriate surgical approachesapproaches

6.6. Secondary AVFs in Secondary AVFs in AFG patientsAFG patients

7.7. AVF AVF evaluation/placement evaluation/placement in catheter ptsin catheter pts

8.8. Cannulation trainingCannulation training9.9. Monitoring and Monitoring and

maintenancemaintenance10.10. Continuing EducationContinuing Education11.11. Outcomes feedbackOutcomes feedback

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Improvement in Improvement in Prevalent Prevalent AVF AVF Rates Rates by ESRD Networkby ESRD Network

FFBI AVF goal 66%66%

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FFBI AccomplishmentsFFBI Accomplishments Website Updates Ongoing (fistulafirst.org) Calendar of upcoming vascular meetings

(including Networks) Tab for Patient Education materials (patient and

professionals) New interventionist videos uploaded Country-wide workshop for surgeons • More Cannulation DVD reproduction in the

works FF Provider Resource List and FAQs FF Patient Resource List

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FFBI Accomplishments (cont).FFBI Accomplishments (cont).

Information sheets on Change Concepts #6 & #9 Monitoring and surveillance flowchart (CC#9)

Secondary AVF Protocols (CC#6) Secondary AVF Sleeves Up Exam Checklist Access Managers (CC#6) Additional Buttonhole slide set (sharp needles)

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FFBI Strategies to increase AVF FFBI Strategies to increase AVF rate and reduce catheter rate:rate and reduce catheter rate:

Networks should mount an effort to re- educate and provide feedback on Change Package, to all Providers and Clinics that are below the mean, including the laggards……

attempt to focus on gaps in education and performanceperformance

Everyone focus on Change Concepts #6 & #7 – and related FF protocols (fistulafirst.org)

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Strategies to increase Secondary Strategies to increase Secondary Fistulae:Fistulae:

Re-evaluation of all patients for AVF options: Conversion of existing AVG to AVF, utilizing

outflow vein of graft for AVF where feasible OR:

Exam & Vessel Mapping for alternate options Secondary A-V Fistula Options K/DOQI guideline 29: Every patient should be

evaluated for a secondary fistula after each episode of graft failure

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“Sleeves Up” Exam Followed by Fistulogram

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Planning for a secondary AVF is Planning for a secondary AVF is criticalcritical

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TIMING of Conversion AVG to a TIMING of Conversion AVG to a Secondary AVFSecondary AVF

1st AVG failure triggers evaluation for conversion to a secondary AVF—and a plan is established…..

2nd AVG failure triggers conversion to an AVF using the fistulogram from the AVG study to evaluate the outflow veins

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Proactive strategies to increase Proactive strategies to increase AVF Rate:AVF Rate:

Early Referral to Nephrologist & Surgeon – (Patient education/ vessel preservation/ no PICC lines if GFR<45)

Surgical Evaluation (& Placement) of Permanent Access during initial Hospitalization

Vessel mapping/Optimal vessel selection to Increase successful (usable) AVFs & Reduce non-maturing (FTM) AVFs (post-op exam @ 4 wks)

Monitoring & Timely Intervention for late failure / Aggressive Salvage

Conversion of AVG to secondary AVF (use FFBI protocol)

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Reactive strategies to increase AVF Reactive strategies to increase AVF rates (All HD patients with rates (All HD patients with

Catheters)Catheters) Regardless of prior access, nephrologists

and surgeons evaluate all catheter patients as soon as possible for AVF

Protocol for Catheter Indications & Removal- Early recognition & intervention for non- maturing AVFs (post-op exam @ 4 wks)—use FFBI protocol

Monitoring & Timely Intervention for late failure/ Aggressive salvage

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The non-Maturing AVFThe non-Maturing AVF

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AVF Dysfunction/failure to mature AVF Dysfunction/failure to mature (FTM)(FTM)

> 30% of new AVFs fail to mature(FTM)Can markedly reduce early failure rate and interventions in

AVFs by:

Early referral & CKD program = improved patient & vessel selection/ standardized vessel mapping protocol

Early recognition of FTM AVF by evaluation (Monitoring & Surveillance) at 4 wks. & timely

intervention=high salvage rate (CC# 9)

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“NO FISTULA LEFT BEHIND”

CLINICS NEED TO TRACK NEW AVFs……and TAKE ACTION (Evaluate, Refer, Intervene) on

AVFs that are:

1) not adequately maturing at 4-6 weeks

2) have reached 3 months and still cannot be used for 2-needle dialysis

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V626 QAPI Condition StatementV626 QAPI Condition Statement

The dialysis facility must develop, implement, The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, maintain and evaluate an effective, data driven, quality assessment and performance improvement quality assessment and performance improvement program with participation by the professional program with participation by the professional members of the interdisciplinary team...members of the interdisciplinary team...

……The dialysis facility must maintain and The dialysis facility must maintain and demonstrate evidence of its quality demonstrate evidence of its quality improvement and performance improvement improvement and performance improvement program for review by CMSprogram for review by CMS

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Condition 494.110:Condition 494.110:Quality Assessment and Performance Quality Assessment and Performance

Improvement Project (Improvement Project (QAPI)QAPI)

Interdisciplinary team (IDT)Interdisciplinary team (IDT) Must report problems to Medical Director and Must report problems to Medical Director and

QAPIQAPI Outcome- focused Outcome- focused Process continuous & on-goingProcess continuous & on-going Use community accepted standards as targetsUse community accepted standards as targets Include patient satisfaction, infection control, Include patient satisfaction, infection control,

medical injuries & medication errorsmedical injuries & medication errors Plan/Do/Check/Act: Close the loop!Plan/Do/Check/Act: Close the loop!

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PDCA /PDSA StylePDCA /PDSA Style

PLAN

DOCHECK/STUDY

ACT

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Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe Progress

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Performance Measures Performance Measures

(V629) Adequacy Kt/V, URR

(V630) Nutrition Albumin, body weight

(V631) Bone disease PTH, Ca+, Phos

(V632) Anemia Hgb, Ferritin

(V633)Vascular access Fistula, catheter rate

(V634) Medical errors Frequency of specific errors

V635) Reuse Adverse outcomes

(V636) Pt satisfaction Survey scores

(V637) Infection control Infections, vaccination status

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Monitoring Performance Monitoring Performance ImprovementImprovement

(V638) The facility must:(V638) The facility must: Continuously monitor its performanceContinuously monitor its performance Take actions that result in performance Take actions that result in performance

improvementimprovement Track to assure improvements are sustained over Track to assure improvements are sustained over

timetime

Inclusion Criteria for Inclusion Criteria for Participating FacilitiesParticipating Facilities

AVF rate < 50% (April SIMS data)AVF rate < 50% (April SIMS data) Highest percentage and number of AV Highest percentage and number of AV

Fistulas placed but not used (source: SIMS Fistulas placed but not used (source: SIMS vascular access monthly reports)vascular access monthly reports)

Patients census Patients census >> 50 patients 50 patients Administrative support: All intervention Administrative support: All intervention

facilities have a stable leadership facilities have a stable leadership

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Exclusion CriteriaExclusion Criteria

Patient census < 50 patientsPatient census < 50 patients Facilities already included in another QIWP Facilities already included in another QIWP

project with the Networkproject with the Network

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ENVIRONMENTAL SCAN ENVIRONMENTAL SCAN RESULTSRESULTS

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Top reasons for fistulas not Top reasons for fistulas not maturing:maturing:

Patient does not exercise arm/lack of patient Patient does not exercise arm/lack of patient education on vascular access care education on vascular access care

Need a surgeon with good technique/surgeon Need a surgeon with good technique/surgeon performance performance

Longer maturation time Longer maturation time Patient’s age group (older the patient, less Patient’s age group (older the patient, less

chance of AVF maturing) chance of AVF maturing) Overall patient’s condition Overall patient’s condition

(multi-level)/Multiple medical conditions (multi-level)/Multiple medical conditions 32

TOP RESOURCES/EDUCATION TOP RESOURCES/EDUCATION REQUESTS (for Patients)REQUESTS (for Patients)

Better illustrations of vascular accesses – Better illustrations of vascular accesses – listing CONS only (Spanish)listing CONS only (Spanish)

Educational material on vascular access Educational material on vascular access types and benefits over a catheter (Spanish)types and benefits over a catheter (Spanish)

Handouts for patients about AVF Handouts for patients about AVF maturation (Exercise for arm)maturation (Exercise for arm)

Pre-ESRD classes for patientsPre-ESRD classes for patients Patient education on vascular access carePatient education on vascular access care

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Education Materials: StaffEducation Materials: Staff

In-service on access education In-service on access education Cannulation in-service for primary Cannulation in-service for primary

cannulators for new AVFscannulators for new AVFs Transonic study machineTransonic study machine Staff education on the maturation processStaff education on the maturation process

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Education (cont).Education (cont).

Nephrologists/Surgeons education on Nephrologists/Surgeons education on vascular accessvascular access

Catheter care for SNF staff to prevent Catheter care for SNF staff to prevent infectionsinfections

Need good surgeons in the areaNeed good surgeons in the area Nephrologists need to partner with good Nephrologists need to partner with good

surgeonssurgeons

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Look, Listen,Feel

AngioplastyFistulagram

Thrombectomy

Continuum of Vascular Access Care

Assessment

Monitoring and Surveillance

Interventions

Documentation

“Everyday” Every shift,

Every patient

Vascular AccessProgram

CQIStatic pressure

DVPRecirculation

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Back to the basics:Back to the basics: Physical Assessment Physical Assessment of Vascular Access is critical!!!!of Vascular Access is critical!!!!

Inspection (look)Inspection (look) Auscultation (listen)Auscultation (listen) Palpation (feel)Palpation (feel)

Use all of your senses for assessment and thenUse all of your senses for assessment and thenuse your memory to compare and contrast theuse your memory to compare and contrast the

condition of the access to previous assessmentscondition of the access to previous assessments

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Inspection: Inspection: LookLook– General development- AVFGeneral development- AVF– Skin conditionSkin condition– ?? Aneurysms/ Pseudoaneurysms?? Aneurysms/ Pseudoaneurysms– Skin color of extremities (warm and dry)Skin color of extremities (warm and dry)– Any swelling ( is there symmetry)Any swelling ( is there symmetry)– Any sign of infectionAny sign of infection– Capillary refill < 2-3 seconds, look for ischemic Capillary refill < 2-3 seconds, look for ischemic

spots on finger tipsspots on finger tips

InspectionInspection

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InspectionInspection

RednessRedness DrainageDrainage AbscessAbscess

Skin ColorSkin Color EdemaEdema Small blue Small blue

Purple veinsPurple veins

Hands: cold, painful, Hands: cold, painful, numbnumb

Fingers: discoloredFingers: discoloredInfection

Central or Outflow

Veinstenosis

Steal Syndrome

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AuscultationAuscultation

Auscultation: Auscultation: ListenListen– Quality and amplitude of bruitQuality and amplitude of bruit– Note pitch changes Note pitch changes – Systolic and diastolic are louder on the arterial Systolic and diastolic are louder on the arterial

sideside– Pitch changes at areas of stenosisPitch changes at areas of stenosis– Whistle or cough sound in the accessWhistle or cough sound in the access

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PalpationPalpation

Palpation: Palpation: FeelFeel– Thrill or pulsation Thrill or pulsation – Normally a thrill present at the anatomists site, Normally a thrill present at the anatomists site,

and disappears after you manually occlude the and disappears after you manually occlude the AVFAVF

– If thrill remains = accessory veinsIf thrill remains = accessory veins– The thrill should lessen going to the venous The thrill should lessen going to the venous

limb of the accesslimb of the access– Thrill can be felt at the site of stenosisThrill can be felt at the site of stenosis

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Palpation (cont).Palpation (cont).

Vein DiameterVein Diameter

- Feel the entire length of the AVF- Feel the entire length of the AVF

- Evaluate for needle site selection- Evaluate for needle site selection

- Check for flat spots – you can see a- Check for flat spots – you can see a

stenosis and feel its thrillstenosis and feel its thrill

- Evaluate if new AVF is ready to - Evaluate if new AVF is ready to

cannulatecannulate

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Fistula ExamFistula Exam

Raise the access arm above the heartRaise the access arm above the heart– The fistula should completely collapseThe fistula should completely collapse– Stenosis located at area of engorgementStenosis located at area of engorgement– Evaluate arterial inflowEvaluate arterial inflow

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Is New AVF Mature? Use the KDOQI Is New AVF Mature? Use the KDOQI “RULE“RULE ofof 6’s”6’s”

6 - 8 week Post OpCheck AVF Maturation

Diameter Greater than

66 mm

Depth below skin Approximately

6 6 mm

Access Blood Flow Greater than

600 600 mL/Min

6 cm of straight segment

“ “ Rule of 6’s Rule of 6’s ””

Vein Vein MUSTMUST Mature Mature PRIORPRIOR to the to the FIRSTFIRST cannulation cannulation

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Is the Access Working Properly?Is the Access Working Properly?

Clearances (URR) greater than 65Clearances (URR) greater than 65 Access flow greater than 600Access flow greater than 600 Venous pressure at 200 BRF less than 125Venous pressure at 200 BRF less than 125 Able to run prescriptionAble to run prescription Other signs and symptoms of access pathologyOther signs and symptoms of access pathology

– RecirculationRecirculation– Difficulty cannulating and pain in the accessDifficulty cannulating and pain in the access– Changes in thrill and bruitChanges in thrill and bruit– Prolonged bleeding post-dialysisProlonged bleeding post-dialysis

Aims to Action: Conducting Aims to Action: Conducting QAPI utilizing Rapid-Cycle QAPI utilizing Rapid-Cycle

ImprovementImprovement

What is Rapid Cycle What is Rapid Cycle Improvement?Improvement?

Variant of process improvement that:Variant of process improvement that:– relies on existing knowledgerelies on existing knowledge– dramatically shortens discovery processdramatically shortens discovery process– works on “rapid trial & learn” methodworks on “rapid trial & learn” method– relies heavily on actionrelies heavily on action

Model for ImprovementModel for Improvement

What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

Act Plan

Study

Do

Aim

Root-Cause ANALYSIS Root-Cause ANALYSIS (Fishbone Diagram)(Fishbone Diagram)

Determine the problem and create a Determine the problem and create a problem statement (effect). Write it at the problem statement (effect). Write it at the right center of the chartright center of the chart

Brainstorm the major categories of causes Brainstorm the major categories of causes of the problem. Write them as the main of the problem. Write them as the main branches steaming from the center linebranches steaming from the center line

Brainstorm all possible causes of the Brainstorm all possible causes of the problem. Ask “Why did this happen?” problem. Ask “Why did this happen?” about each cause.about each cause.

Root-Cause ANALYSIS Root-Cause ANALYSIS (Fishbone Diagram – cont).(Fishbone Diagram – cont).

Write sub-causes stemming from the Write sub-causes stemming from the category of causescategory of causes

Collect data to confirm root-causeCollect data to confirm root-cause If no further causes can be identified, then If no further causes can be identified, then

you found the root causes of the problemyou found the root causes of the problem

Plan-Do-Study-ActPlan-Do-Study-Act

Plan Plan – Identify Opportunity and plan for change– Identify Opportunity and plan for change Do Do – Implement the Change on a small scale– Implement the Change on a small scale Study –Study – Use data to analyze for the change and Use data to analyze for the change and

determine whether it made a differencedetermine whether it made a difference Act Act – If the change was successful, implement the – If the change was successful, implement the

plan and continuously monitor results. If the plan and continuously monitor results. If the change did not work – start the process again.change did not work – start the process again.

Model for ImprovementModel for Improvement

What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

Act Plan

Study

Do

Aim

Developing Your AimDeveloping Your Aim

Write a clear statement of aim--make the Write a clear statement of aim--make the target for improvement unambiguoustarget for improvement unambiguous

Include numeric goalsInclude numeric goals

Set “stretch” aimsSet “stretch” aims

Focus on issues that are important to your Focus on issues that are important to your organization - choose appropriate goalsorganization - choose appropriate goals

Developing Your AimDeveloping Your Aim Improvement relies onImprovement relies on intentionintention to to

improveimprove Senior leaders set & align aim with Senior leaders set & align aim with

strategic goals (involve Medical strategic goals (involve Medical Director!)Director!)

Agreement on aim is criticalAgreement on aim is critical Include a specific time frame for Include a specific time frame for

accomplishing your aimaccomplishing your aim

Examples of AimsExamples of Aims

70% of all dialysis patients with AVFs created 70% of all dialysis patients with AVFs created after April 2008 will be functional by January after April 2008 will be functional by January 20092009

To increase the number of patients utilizing To increase the number of patients utilizing AVF as a primary vascular access for AVF as a primary vascular access for hemodialysis by 6 percentage points between hemodialysis by 6 percentage points between October 2008 and May 2009October 2008 and May 2009

Project Goal:Project Goal:

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To decrease the number of AVFs “placed To decrease the number of AVFs “placed but not used” by 20% between October but not used” by 20% between October 2008 and May 2009 within the group of 2008 and May 2009 within the group of participating facilities (N=13)participating facilities (N=13)

Based on the responses from 13 facilities Based on the responses from 13 facilities the total number of AVF’s “placed but not the total number of AVF’s “placed but not used” was 215.used” was 215.

Need to identify target patients with AVFs Need to identify target patients with AVFs created after April 2008 to establish a created after April 2008 to establish a baseline baseline

Target Patients:Target Patients:

Every facility should identify target patients Every facility should identify target patients with fistulas created after April 2008with fistulas created after April 2008

AVFs created before April 2008 should not AVFs created before April 2008 should not be considered as “awaiting maturation” and be considered as “awaiting maturation” and these patients should have a new vascular these patients should have a new vascular access plan createdaccess plan created

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Technical Expertise

Day-to-dayLeadership

System Leadership

Three Ingredients of an Three Ingredients of an Effective TeamEffective Team

Establishing Your TeamEstablishing Your Team

Have day-to-day, system, and technical expertiseHave day-to-day, system, and technical expertise– Day-to-day leader gives at least 20% (loses Day-to-day leader gives at least 20% (loses

sleep)sleep)– System leader can arrange for the resources to System leader can arrange for the resources to

do the workdo the work– Technical experts know the subject matter--Technical experts know the subject matter--

often bedside peopleoften bedside people

Use interdisciplinary team (IDT)Use interdisciplinary team (IDT)

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Interdisciplinary Team:Interdisciplinary Team:

Show Me Show Me The ProgressThe Progress

Using Data for ImprovementUsing Data for Improvement

Model for ImprovementModel for Improvement

What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

Act Plan

Study

Do

Measure

Measurement GuidelinesMeasurement Guidelines

The key measures should clarify the aim and The key measures should clarify the aim and make it tangiblemake it tangible

Use outcome and process measures Use outcome and process measures

Integrate measurement into the daily routineIntegrate measurement into the daily routine

Use qualitative as well as quantitative dataUse qualitative as well as quantitative data

Seek usefulness, not perfectionSeek usefulness, not perfection

Measures:Measures:

Process:Process: Identify patients with Identify patients with

AVFs that were placed AVFs that were placed after April 2008 but not after April 2008 but not used yet.used yet.

Vascular access Vascular access assessment assessment

Cannulation LogCannulation Log P-t referral logsP-t referral logs Monitor newly created Monitor newly created

AVF for maturationAVF for maturation

Outcome:Outcome: Decrease in number of Decrease in number of

AVF “placed but not AVF “placed but not used”used”

Increase in number of Increase in number of functional AVFsfunctional AVFs

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Model for ImprovementModel for Improvement

What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

Act Plan

Study

Do Select Changes

Selecting ChangesSelecting Changes Blatantly stealBlatantly steal: Use the literature, the : Use the literature, the

experience of others, hunches and theories experience of others, hunches and theories (FFBI suggestions)(FFBI suggestions)

Be strategic: Set priorities based on the aim, Be strategic: Set priorities based on the aim, known problems, and feasibilityknown problems, and feasibility

Objective of the Test:Objective of the Test:Change or No Change?Change or No Change?

Probably ChangeProbably Change

TestTest

RedesignRedesign

EliminateEliminate

ReduceReduce

DeliverDeliver

ImplementImplement

Probably No ChangeProbably No ChangeRecruitRecruitDistributeDistributeContinueContinueExamineExamineDiscussDiscussTeachTeach

Selecting ChangesSelecting Changes Test the changes on a small scale Test the changes on a small scale

- “By next Tuesday”- “By next Tuesday” - Capitalize on curiosity- Capitalize on curiosity - Have a bias for the “doable”- Have a bias for the “doable”

Use change conceptsUse change concepts-Simplify-Simplify

-Error-proof-Error-proof -Minimize the hand-offs-Minimize the hand-offs

To Be Considered a Real TestTo Be Considered a Real Test Test was planned, including a plan for Test was planned, including a plan for

collecting data.collecting data. Plan was attempted and data was Plan was attempted and data was

collected.collected. Time was set aside to analyze data and Time was set aside to analyze data and

study the results.study the results. Action was taken, based on what was Action was taken, based on what was

learned.learned.

Small scale Small scale small change small change Success (or failure) in one PDSA cycle Success (or failure) in one PDSA cycle

success or failure of the projectsuccess or failure of the project

Two Key PointsTwo Key Points

AVF Maturation Project:AVF Maturation Project:Network Responsibilities:Network Responsibilities:

Project Leader (change agent)Project Leader (change agent) Supply the templates for RCA & PDSASupply the templates for RCA & PDSA Supply toolkits to facilities & evaluate their Supply toolkits to facilities & evaluate their

usefulnessusefulness Provide monthly feedback (Vascular Access Provide monthly feedback (Vascular Access

SIMS reports)SIMS reports) Conduct monthly phone interviews to obtain Conduct monthly phone interviews to obtain

facility-specific datafacility-specific data Facility site visits for strugglersFacility site visits for strugglers

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Facilities Responsibilities:Facilities Responsibilities: Return agreement letter (signed by MD)Return agreement letter (signed by MD) RCA & PDSA due to the Network by RCA & PDSA due to the Network by

November 14, 2008 (PDSA must be signed November 14, 2008 (PDSA must be signed by MD)by MD)

Review toolkit and identify tools that would Review toolkit and identify tools that would work in your facilitywork in your facility

Follow the project timelinesFollow the project timelines

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We are all partners!We are all partners!

Thank you!Thank you!

For questions please contact:For questions please contact:

Svetlana (Lana) Kacherova, RN, MPH, CPHQSvetlana (Lana) Kacherova, RN, MPH, CPHQ

Quality Improvement DirectorQuality Improvement Director

ESRD Network 18ESRD Network 18

323-962-2020323-962-2020

skacherova@nw18.esrd.netskacherova@nw18.esrd.net