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Webinar 2 March 28, 2017

AIM 1:Vaccinations Interventions and Outcomes Discussion Dany Anchia, RN Quality Improvement Coordinator. Webinar 2 March 28, 2017. Objectives. Review Project Goals Root Cause Analysis Findings Questions and Answer Session Intervention Outcomes Discussion Review Vaccination Data entry

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Webinar 2 March 28, 2017

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  1. AIM 1:VaccinationsInterventions and Outcomes DiscussionDany Anchia, RNQuality Improvement Coordinator Webinar 2 March 28, 2017

  2. Objectives • Review Project Goals • Root Cause Analysis Findings • Questions and Answer Session • Intervention Outcomes Discussion • Review Vaccination Data entry • Attestation & Polling via Survey Monkey • Next Steps

  3. CMS watchlist • Facilities failing to submit required documentation for projects will receive: • One written or emailed notice • One notification via phone • If no response received from facility, the facility will be placed on the CMS Watchlist, which will include: • Report of non-compliance to corporate leaders (if applicable) • Report of non-compliance with DSHS on monthly calls • Report of non-compliance to CMS

  4. Goals Review • ESRD Network 14 vaccination rate: 54.7% • Hepatitis B vaccination rate: 65.3% • Pneumococcal vaccination rate: 37.2% • Focus Facilities in this project: 33.3% • Hepatitis B vaccination rate: 37.7% (16.6% in 2016) • Target rate: 40.7% (3 percentage point increase) • Pneumococcal vaccination rate: 28.8% (3.5% in 2016) • Target rate: 31.8% (3 percentage point increase) *Facilities will remain in project until they achieve at least 60% vaccination rates for each measure

  5. 2017 RCA Findings Environmental/Places Factors People: Patient/Family Related Factors

  6. 2017 RCA Findings Organizational/Systemic/Policies factors Products/Material Factors

  7. 2017 RCA Findings (Other Factors)

  8. Let’s Discuss

  9. Clinical Data Entry • Collection Type • Hemodialysis and Peritoneal dialysis

  10. Clinical month • Clinical Month • Inaccurate vaccination data for patients on the tool discharged prior to March/April 1, 2016, cannot be corrected. • Contact Corporate and/or QualityNet Help Desk

  11. Select Patient

  12. Vaccination—ppv Search through Medical Records or ask the patient Enter the year the patient received PPV, even if it was not provided by your unit.

  13. Vaccination—HBV Initial Enter the date the patient received HBV, even if it was not provided by your unit.

  14. Vaccination—HBV Booster/anti-hbs Enter the dates the patient received HBV boosters, even if it was not provided by your unit. Enter the anti-HBs data, if applicable, whether or not you have HBV initial or booster dates.

  15. Vaccination—Anti-hbs You do not have a date for HBV vaccination, but you have a positive result for HBV antibodies. Do not select “Not Received”; select “N/A” for Initial 1. You do not have a date for HBV boosters; select “N/A” for Booster Date 1. Enter the HBV antibodies value and date in the anti-HBs field (can be before 2015).

  16. Objectives • Review Project Goals • Root Cause Analysis Findings • Question and Answer Session • Intervention Outcomes Discussion • Review Vaccination Data entry • Attestation & Polling via Survey Monkey • Next Steps

  17. Next Steps • Complete Attestation and Polling to receive credit for attending webinar 2 • Based on your Root Cause of Low Vaccination Rates develop and implement at least one of the following: • Implement Vaccination Discussion Groups • Implement Vaccination Awareness Campaign • Your own Plan of Action based on sound methodology (template with sample available on our website at: http://www.esrdnetwork.org/core-long-term-catheter-qia) • Deadline: Monday May 1, 2017 • In addition, continue to contact corporate and/or QualityNet Help Desk to correct any data issues you find

  18. Network Resources • Project Materials and Resources (look for the vaccinations logo) • http://www.esrdnetwork.org • For: • Timeline • Webinar Info • Slides • Tools • Click here

  19. wEbinar Evaluation & Questions • Complete the webinar evaluation via survey monkey link providing your name, facility name, and 6-digit CMS certified facility number(CCN#). This will serve as record of your attendance (a project requirement) at today’s webinar(posted in the chat right now OR on our website if you missed the webinar) • Questions • Vaccinations project • *Dany Anchia, danchia@nw14.esrd.net, 469-916-3813 • Outreach Coordinator • Javoszia Sterling, jsterling@nw14.esrd.net, 469-916-3800 • QualityNet Help Desk • 866-288-8912, qnetsupport-esrd@hcqis.org *Project lead

  20. Thank you

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