Facilities Involved in QIA

Network 1 Network 2 Network 6 Network 9

Long-Term Catheters (LTC) >90 Days Goal is <10%

Project Guide

Project Agreements/Contracts due back to the Network

Projects Guides by Network: Network 1, Network 2, Network 6, Network 9

Project Webinars and Materials; Additional Vascular Access Improvement Materials

Vascular Access Planning (VAP) Facility Workbook; (VAP) Reporting Form

*If you have <25 patients, contact your Network

When reviewing your data, consider the following:

  • How do your AVF and LTC rates compare to the CMS AVF goal of 68% and LTC goal of less than 10%?
  • Will your facility get maximum reimbursement in 2018 based on your performance for 2016 on the QIP?
  • How does your AVF and LTC rate compare to the Network and National averages?
  • What are the AVF/LTC goals for your facility? What steps might you take to maintain/improve rates?
  • What access types   may need to be corrected prior to the closure of the next clinical month?

STEP 1: Develop a Vascular Access Corrective Action Plan (CAP)  

  • Complete all sections of the CAP – If you have a corporate plan you may send this instead if it includes the same information
  • Root causes should be identified with action steps to address each root cause
  • Develop a performance measure to use during monthly QAPI meetings to ensure the action step is being done or is yielding the outcome desired, if not discuss and alter plan during this meeting
  • Return completed CAP to Network when requested

STEP 2: If no improvement has been made for 3 consecutive months, Identify 3 action steps to support the CAP for each quarter(3 month period)

  • Quarterly Action Report Template 
  • Submit action steps using the Quarterly Report Form by the end of the following 3 months:
    January, April, and July (CT, MA, ME, NH, RI, VT - NW1) (NY - NW 2) (IN, KY, OH - NW 9)
    July and October (GA, NC, SC - NW 6) 
  • Describe results of these actions and provide a summary when submitting for the next quarter: 
    April, July, and October (CT, MA, ME, NH, RI, VT - NW 1) (NY - NW 2) (IN, KY, OH - NW 9) 
    July and October (GA, NC, SC - NW 6)

STEP 3: Use the Vascular Access Tracker   to monitor your patient’s progress (Instructions for use)

  • If no progress is made for 3 consecutive months, this tool may be audited by Network staff; If you have an alternate tracking system, you may use your corporate system to complete this obligation

STEP 4: Attend mandatory webinar series: Instructions for Registration

STEP 5: Verify your data monthly comparing your facility system and CROWNWeb

patient dialysis access

Initiative Contacts:

Network 1 (CT, MA, ME, NH, RI, VT)
Kristin Brickel, RN, MSN, MHA, CNN
Quality Improvement Director

Network 2 (NY)
Carol Lyden, RN, BSN, MS, CNN
Quality Improvement Director

Network 6 (GA, NC, SC)
 Wambui Kungu, BS, HSM
Quality Improvement Coordinator

Network 9 (IN, KY, OH)
Susan Swan-Blohm
Quality Improvement Coordinator