IPRO ESRD Network of the South Atlantic is implementing CMS designated activities to increase overall Kt/V at the facility level. Facilities will be provided with root cause analysis (RCA) templates that the Network will review with the project team to develop a Plan Do Study Act (PDSA) Plan for improving Kt/V.
AIM: Impact 10 or more Network facilities with the poorest performance on the QIP measure Kt/V. Requirement is to maintain 10 participating facilities throughout the project period.
Baseline: Baseline is 2016; variable for new facilities. Re-measure will be rolling a three month average of Kt/V.
Goal and Timeline: In order graduate out of the project a facility must improve on this measure by 25% relative improvement from baseline or exceed the QIP threshold for this measure.