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

(Vascular Access, 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 facility’s % 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 isn’t working? No process or process isn’t 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 (they’ll 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, Inc. Revised 07-2011
  See Page 2 for Sample Quality Improvement Plan Template 
Developed by ESRD Network of Texas, Inc. Revised 07-2011
 SAMPLE ONLY - Page 2
SAMPLE Quality Improvement Plan Template
Facility Name: ABC Dialysis Center CMS Certification
Number (CCN): # 55-5555
Date Initiated: July 15, 2011 Date Completed: In progress Team Members
Contact: Ima Nurse, MSN, RN, CNN Facility
1 Dr. Expert, Medical Director
The facility did not meet the CMS Quality Incentive Program goal of no more than
Problem Statement: 2% of patients with a Hemoglobin of of less than 10.0 gm/dL as evidenced by the 2 Ima Nurse, Clinical Manager
July 2011 clinical outcome of 16.4% with Hemoglobin less than 10.0 gm/dL.
3 Kerry Much, Social Worker
4 Eat More, Dietitian
1. The facility will meet or exceed the Medical Review Board anemia cut-point to
Goal: Hemoglobin less than 10.0 gm/dL of less than 20% patients in this category. 5 Jump T. Hoops, Charge Nurse
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.* 6 Talented Clinician, Patient Care Technician
Root Cause(s): External
1. Failure to have an evidence-based standardized anemia protocol in place for anemia management. 1 ESA Vendor & Iron Vendor
2. Failure to have a designated anemia manager. 2 Corporate/Ownership
3. Failure to administer maintenance doses of Iron as needed. 3 ESRD Network of Texas, Inc.
Barrier(s):
1. Staff turnover.
2. Unfamiliar with iron dosing guidelines.
3. Lack of tools/resources to determine root cause of severe anemia in patients.

Person(s) in
Task to be Completed Actions & Steps Resources Due Date Charge How will I know if the change is an improvement?
1. Post ads in various locations.
Hire another charge 1. Corporate/Ownership to
2. Offer a sign on bonus to be Dr. Expert
capable, experienced allocate funding.
paid incrementally over a 2 year Ima Nurse Fully qualified RN, charge capable will be hired and begin working in the facility taking on the anemia
charge nurse with anemia 2. Corporate/Ownership to August 1, 2011
period. 3. Mandate Corporate/ management duties.
management determine where to place ads.
dialysis\experience and charge Ownership
responsibilities. 3. Accept and review resumes.
eligibility.

1. Arrange ESA & Iron Vendors to 1. ESA Vendor Dr. Expert

visit and provide guidelines. 2. Iron Vendor Ima Nurse
Develop and implement a Implement an evidence based anemia management protocol which will be effective for at least 90% of the
2. Medical Driector, CM and CN 3. Obtain sample protocol CN (Anemia
formal anemia protocol for August 1, 2011 facility patients. The protocol once implemented will maintain patient's Hemoglobins above 10.0 gm/dL but
(anemia Manager) to meet and recommendations from both Manager)
use in the facility. not higher than 11.0 gm/dL.
develop/design effective anemia vendors for dosing and testing ESA Vendor
protocol to use for facility. guidelines. Iron Vendor

1. Staff inservice/professional CN (Anemia

Initiate the use of various
tools and resources
available from the ESRD
Network of Texas Anemia
Management Quality
Improvement Project.
education on anemia Manager)
1. Obtain copy of the tools and management Ima Nurse
resources: Run Charts, Severe 2. Staff orientation to use of Development of a comprehensive educational initiatives - all staff and all patients utilizing the tools and
Jump T.
Anemia Root Cause Analysis Tools, anemia educational tools for resources from the ESRD Network of Texas Anemia Management Quality Improvement Project
Hoops Eat
professional education resources, patients/reinforcement of (www.esrdnetwork.org - Professionals - Quality Improvement - Anemia Management). Bi-weekly review of all
More
patient educational resources and education. 3. anemia clinical indicator outcomes, complete with use of run charts, report cards, anemia protocol, and root
August 31, 2011 Kerry Much
Report Cards (HD & PD). Perfomance of root cause cause analysis documentation. Formal anemia management education will be provided by all staff to all
Tal. Clinician
2. Monthly educational activity for analysis to determine root cause patients on a routine basis (with the anemia manager in the lead). Dietitian and Social Worker will facilitate
All
staff and patients in order to ensure of anemia in those patients not all educational initiatives by providing supportive education and assistance with overcoming identified barriers
Staff All
continued focus on anemia outcomes responding as expected. to achieving goals.
Patients ESRD
until issue resolved and goal met.
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.

0000CCDeveloped by ESRD Network of Texas, Inc. (Network # 14) July 2011

 Quality Improvement Action Plan
Facility Name: CMS Certification
Number (CCN):
Date Initiated: Date Completed: Team Members
Contact: Facility
1
Problem Statement: 2
3
4
Goal: 5
6
Root Cause(s): External
1
2
3
Barrier(s):

Person(s) in
Task to be Completed Actions & Steps Resources Due Date Charge How will I know if the change is an improvement?

* 0000CCDeveloped by ESRD Network of Texas, Inc. (Network # 14) July 2011