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Quality Improvement

The quality improvement (QI) program encompasses:

  • Identifying opportunities for improvement
  • Analyzing available data sources
  • Prioritizing interventions for maximum impact in an efficient manner
  • Measuring the effectiveness of interventions and activities
  • When possible, changing methodologies spontaneously if interventions don't seem to be working as well as desired

Our QI goals are established by the Network's contract with the Centers for Medicare & Medicaid Services, refined by scrutinizing all available data on facility performance, then reviewed and approved by the Network's medical review board. We assess and revise program intentions and goals at least annually.

Quality Improvement Activities

ESRD Online

ESRD Online is the hub for Network dialysis facilities to complete CMS-required quality improvement activities and projects. In ESRD Online you can:

  • Report data directly to the Network
  • Track your progress on CMS-required activities (Facility Status Update Report)
  • Access the Network resource library
  • Use a team approach to complete requirements

We give login information to all facility administrators. This can be shared with any staff members assisting in meeting CMS goals and requirements.

  • Username: Facility CCN
  • Password: Contact your facility administrator for the password

For help with ESRD Online or your password, email ESRDData@comagine.org.

QAPI Process

42 CFR 494.110 — Condition: Quality assessment
and performance improvement.

“The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.”

Interpretative Guidance

“There must be an operationalized, written plan describing the QAPI program, scope, objectives, organization, responsibilities of all participants, and procedures for overseeing the effectiveness of monitoring, assessing and problem-solving activities….

“The important aspects of the QAPI program are appropriately monitoring data/information; prioritizing areas for improvement; determining potential root causes; developing, implementing, evaluating, and revising plans that result in improvements in care.

“Records of QAPI activities including minutes or another method of demonstrating this analysis and action must be available for review.”

Many companies have policies/procedures for quality assessment and performance improvement. The Network considers the Institute for Healthcare Improvement to be an excellent resource for quality improvement. Access the IHI QI Essentials Toolkit.