TIPS - Writing a Quality of Care Improvement Plan For a Clinical Outcome

(Anemia Management, Adequacy, Bone & Mineral Management, etc.)

1. During Quality Assessment and Performance Improvement (QAPI) meetings, ASK THESE QUESTIONS:
What goals does your facility have for this outcome do you use corporate/facility goals, K/DOQI goals, Network #14 MRB Cut-Points?
Review the % of your facility patients that are achieving the desired goal(s) for the outcome.
For example, using your most recent lab results, what % of your patients have a Hgb less than 10.0gm/dl?
What % of your facility patients achieved the desired goal for the outcome rate 1 year ago, 6 months ago, 3 months ago?
How does your facility track and trend the outcome do you use trend/run charts?
Who tracks and trends the outcome?
If your facility does not meet an outcome goal, what is your current process for improving the outcome?
What staff member(s) are responsible for implementing your process for improving the outcome?
What resources are available to assist you in reviewing and revising your process for outcome improvement? (Vendor clinical support staff,
NW QI staff, K/DOQI Guidelines, if corporate policies, quality managers, etc.)
Brainstorm:
What are the barriers that make it difficult for your facility to achieve the desired goal for the outcome?
Where are you strongest? Where are you weakest? Where are you making progress?
As a team, pick 2-3 strategies that have the potential to:
Increase your facilitys % of patients achieving the desired clinical outcome.
Be accomplished relatively quickly and easily.
Hint pick the actions that give you the most bang for the buck, yet can still be done quickly and easily.

2. As a team, discuss each action and decide on the answers to these questions:
What is the problem or issue (identified need) that the action would target?
Why is this a problem area Team communication? Process in place isnt working? No process or process isnt used? Patient non-
adherence?
What action does your team want to take to address the problem area?

3. Start drafting your Improvement Plan see Page 2 for an example of how to write an Improvement Plan.
List the individual steps or tasks that would need to be completed to accomplish the action.
What additional resources (time, printing costs, phone calls, etc) if any, will be needed for each step/task?
Decide on a due date when each step/task within the broader action should be completed.
Assign someone to be in charge of each step or task ask for volunteers first (theyll have the most incentive).
Decide how you will evaluate the success of each step or task AND of the action as a whole:
Is the step/task being done consistently and according to the plan?
Does the performance of the task/step need to be documented and trended using an audit tool?
Can facility data be compared at the beginning of each step/task (baseline data) and at the end of each step/task?
Are there subjective ways you can tell if your step/task if working?

See Page 2 for Sample Quality Improvement Plan Template
Developed by ESRD Network of Texas, I nc. Revised 07-2011




SAMPLE ONLY - Page 2
SAMPLE Quality Improvement Plan Template
Date Initiated:
July 15, 2011 In progress
Contact:
1
Dr. Expert, Medical Director
2
Ima Nurse, Clinical Manager
3
Kerry Much, Social Worker
4
Eat More, Dietitian
5
Jump T. Hoops, Charge Nurse
6
Talented Clinician, Patient Care Technician
Root Cause(s):
1 ESA Vendor & Iron Vendor
2
Corporate/Ownership
3
ESRD Network of Texas, Inc.
Task to be
Completed Actions & Steps Resources Due Date
Person(s) in
Charge
Hire another charge
capable, experienced
charge nurse with anemia
management
responsibilities.
1. Post ads in various locations.
2. Offer a sign on bonus to be paid
incrementally over a 2 year period.
3. Mandate dialysis\experience and
charge eligibility.
1. Corporate/Ownership to
allocate funding.
2. Corporate/Ownership to
determine where to place ads.
3. Accept and review resumes.
August 1, 2011
Dr. Expert
Ima Nurse
Corporate/
Ownership
Develop and implement a
formal anemia protocol for
use in the facility.
1. Arrange ESA & Iron Vendors to
visit and provide guidelines.
2. Medical Driector, CM and CN
(anemia Manager) to meet and
develop/design effective anemia
protocol to use for facility.
1. ESA Vendor
2. Iron Vendor
3. Obtain sample protocol
recommendations from both
vendors for dosing and testing
guidelines.
August 1, 2011
Dr. Expert
Ima Nurse
CN (Anemia
Manager)
ESA Vendor
Iron Vendor
Initiate the use of various
tools and resources
available from the ESRD
Network of Texas Anemia
Management Quality
Improvement Project.
1. Obtain copy of the tools and
resources: Run Charts, Severe
Anemia Root Cause Analysis Tools,
professional education resources,
patient educational resources and
Report Cards (HD & PD).
2. Monthly educational activity for
staff and patients in order to ensure
continued focus on anemia outcomes
until issue resolved and goal met.
1. Staff inservice/professional
education on anemia
management
2. Staff orientation to use of
anemia educational tools for
patients/reinforcement of
education. 3.
Perfomance of root cause
analysis to determine root cause
of anemia in those patients not
responding as expected.
August 31, 2011
CN (Anemia
Manager)
Ima Nurse
Jump T. Hoops
Eat More
Kerry Much
Tal. Clinician
All Staff
All Patients
ESRD Network
of Texas
* The CMS Quality Incentive Program, implemented the "penalty for poor performace" for a possible 2% of reimbursement at risk. The calculations to determine the complete reimbrsement "penalty" is available in Levy, Jr., R. (2011). Medicare
Issues Final Rule on Quality Incentive Program, Dialysis & Transplantation, Volume 40: Number 2: February 2011, page 57 or the ESRD Network of Texas, Inc. NetLink, April 2011, Article named "Bundling", available on the website at:
www.esrdnetwork.org - Our Network - Newsletters - NetLinks. Severe anemia (defined as patients' with Hemoglobin less than 10.0 gm/dL which cannot be more than 2% of the facility patient population) is weighted as 50% of the entire 2%
reimbursement reduction.
2. Unfamiliar with iron dosing guidelines.
3. Lack of tools/resources to determine root cause of severe anemia in patients.
How will I know if the change is an improvement?
Fully qualified RN, charge capable will be hired and begin working in the facility taking on the anemia
management duties.
Implement an evidence based anemia management protocol which will be effective for at least 90% of the
facility patients. The protocol once implemented will maintain patient's Hemoglobins above 10.0 gm/dL but
not higher than 11.0 gm/dL.
Development of a comprehensive educational initiatives - all staff and all patients utilizing the tools and
resources from the ESRD Network of Texas Anemia Management Quality Improvement Project
(www.esrdnetwork.org - Professionals - Quality Improvement - Anemia Management). Bi-weekly review of all
anemia clinical indicator outcomes, complete with use of run charts, report cards, anemia protocol, and root
cause analysis documentation. Formal anemia management education will be provided by all staff to all
patients on a routine basis (with the anemia manager in the lead). Dietitian and Social Worker will facilitate all
educational initiatives by providing supportive education and assistance with overcoming identified barriers to
achieving goals.
External
1. Failure to have an evidence-based standardized anemia protocol in place for anemia management.
2. Failure to have a designated anemia manager.
3. Failure to administer maintenance doses of Iron as needed.
Barrier(s):
1. Staff turnover.
Ima Nurse, MSN, RN, CNN Facility
Problem Statement:
The facility did not meet the CMS Quality Incentive Program goal of no more than
2% of patients with a Hemoglobin of of less than 10.0 gm/dL as evidenced by the
July 2011 clinical outcome of 16.4% with Hemoglobin less than 10.0 gm/dL.
Goal:
1. The facility will meet or exceed the Medical Review Board anemia cut-point to
Hemoglobin less than 10.0 gm/dL of less than 20% patients in this category.
2. The facility will achieve the CMS Quality Incentive Program goal of less than 2%
of patients with a Hemoglobin of less than 10.0 gm/dL.*
Facility Name: ABC Dialysis Center
CMS Certification
Number (CCN): # 55-5555
Date Completed:
Team Members
Developed by ESRD Network of Texas, Inc. (Network #14) J uly 2011
Quality Improvement Plan Template
Date Initiated:
Contact:
1
2
3
4
5
6
Root Cause(s):
1
2
3
Task to be
Completed Actions & Steps Resources Due Date
Person(s) in
Charge How will I know if the change is an improvement?
External
Barrier(s):
Facility
Problem Statement:
Goal:
Facility Name:
Date Completed:
Team Members
CMS Certification
Number (CCN):
* Developed by ESRD Network of Texas, Inc. (Network #14) J uly 2011