1. Network of New England “An Educational Day & Time Out For Technicians” April 24, 2008 Douglas Shemin, MD Network Chairman

3. ESRD Network Organization ESRD Medicare Program Public Law 92-603 in 1972. Medicare coverage for ESRD began July 1973. ESRD Network Coordinating Councils (32 areas) established in 1978, consolidated to 18 networks in 1988. Network Organizations are independent contractors. Performance evaluated by CMS annually. 2/18 networks now administered by QIOs Contracts renewed every 3 years based on performance. Network of New England, Inc. (not-for-profit corporation) has held the ESRD Network contract for 30 years. New contract effective July 1, 2006 for three years.

4. ESRD Network Organization Each network has paid staff, volunteer Board of Directors (BOD), volunteer Medical Review Board (MRB). The MRB reviews, suggests QI projects, reviews grievances and complaints), and patient advisory committee. BOD and MRB made up of nephrologists, nurses, dieticians, social workers, administrators, transplant professionals, patient representatives and technicians. Network of New England welcomes interested renal professionals to our BOD and MRB.

5. What do the Networks do? Collect data (demographics, comorbidity, mortality information) on > 400,000 patients in > 4000 facilities Assess Data: Identify QI needs on a local level, institute and administer QI projects, offer assistance to underperforming facilities Respond to grievances, complaints, concerns by patients, families, and facilities. Special projects

6. New England Provider Distribution

7. Number of ESRD Providers: 2001 & 2006 ESRD Resources in New England 12/31/2001 ESRD Resources in New England 12/31/2006

8. Modality By State: 2001 & 2006 2001 Dialysis Prevalence by Modality: Provider of Service 2006 Dialysis Prevalence by Modality: Provider of Service

9. Dialysis Patient Characteristics in New England Dialysis Population 12/31/2006

10. patients18-54Employedschool CT 3,38996227723 MA5,0911,33435152 RI880208455 VT2915751 NH731194534 ME958228644 Total11,3402,98379589 From Network 1 Annual Report 2006: in New England, 27% working age dialysis patients work, 3% go to school

11. Providers with Treatments after 5PM 20012006 # Dialysis Providers # Providers w/ shift after 5PM # Dialysis Providers # Providers w/ shift after 5PM CT32722%31929% MA672639%742635% ME13646%18528% NH10660%10550% RI14214%18211% VT6480%7686% Total1425136%1585334%

12. Dialysis Providers by Ownership 12/31/2006 For profit chain Hospital Independent, nonprofit Total CT26531 MA512374 ME10818 NH9110 RI15318 VT077 Total11147158 Percent70%30%100%

13. CMS / CPM Data Target 2006 National Report 8,609 Patients 2007 National Report 8,740 Patients Network 2006 National Report 471 Patients Network 2007 National Report 484 Patients IndicatorCMSNetwork Mean URR % > 6580%90%*88% 90 %91% Mean KT/V > 1.284%90%*91%90%92 %94% Mean Hemoglobin > 11 gm/dL (Anemia) 80 % 84% 85 %84% Mean Tsat % > 20%80% 78%80%76 %81% Mean Serum Ferritin % > 100 ng/mL 80% 95% 96 %95% Prevalent Pts with Serum Albumin > 4.0/3.7 gm/dL BCG/BCP (Nutrition) N/A32%33%37%32 %35% Prevalent Pts with Serum Albumin > 3.5/3.2 gm/dL BCG/BCP (Nutrition) 80% 82%80 %79% Prevalent Pts with Catheter > 90 days (Vascular Access) 10% Reduce 3%/yr 21%22%20 % Prevalent Pts with AVF 66% by 2009 > 54.6% by 3/08 44%46%51 %57% *Goals adjusted by the BOD/MRB 6/07. Source: CMS/CPM 2006/2007 report, which has 2005/2006 data. +Serum Albumin is not considered a CPM. Note: Annual random 5% patient sample

14. 4 targets: KT/V > 1.2, Hgb > 11, AVF, albumin > 4 Rocco, Annals Internal Medicine, 2006 1 year death rate 4/4 targets 7 % 3/4 targets14 % 2/4 targets21 % 1/4 targets25 % 0/4 targets29 %

15. Why “Fistula First”? Better solute clearance with AV Fistulae Much lower risk of infection: Sixfold greater rate of bacteremia with catheters (Hosp Inf Disease 2003) Lower risk of death with AV Fistulae: (from CHOICE Study, JASN 2007)—47 % higher adjusted mortality rate in catheter patients compared to AVF patients

16. Prevalent Vascular Access Network # 1 and State Jan. 2007 to Jan. 2008

17. Quality Improvement Initiatives Fistula First increase to 66% by 2009 Clinical Performance Measures for focused intervention –Anemia Management Network Special QI Projects –Catheter reduction –Nutrition management –Patient Safety Facility Specific Quality Assessment and Performance Improvement Projects –Use data profiles to identify providers needing assistance –Provide QI technical assistance to dialysis providers

18. 5 Diamond Patient Safety Program ESRD Network of New England (Network 1) & Mid-Atlantic Renal Coalition (Network 5)

19. Patient Safety Culture Pervasive Commitment to Patient Safety Open Communication Blame-free Environment Safety Design Employee & Physician Involvement & Accountability

20. Objectives To promote patient safety values To create an awareness of patient safety issues To help dialysis units learn more about specific areas of patient safety To build a patient safety culture in every dialysis unit

21. Educational Modules Hand Washing Flu Vaccination Slips, Trips and Falls Medication Reconciliation Emergency Preparedness Sharps Safety Decreasing Patient & Provider Conflict  Patient Safety Principles (required)  Under Development Staff Adherence to Procedures Dialyzer Set-up Errors

22. Each topic is a complete educational module Tools and resources are located on the Network of New England website Required and optional activities PowerPoints for staff in-service presentations Posters for display Games and activities to engage patients Modules

23. Recognition All participants completing at least one component or more will be recognized 1 – 4 Diamonds Acknowledged in Network Newsletter Listed on Network Website

24. Recognition - 5 Diamond Acknowledged in Network Newsletter Listed on Website Special recognition at Annual Network Council Meeting 2 free passes to Annual Meeting $75.00 gift certificate for entertainment material for patients Plaque to display in unit

25. Details Time frame –Starts April 2008 in Network #1 –Launch project at Technician Meeting April 24, 2008 –Mass Mailing to all Providers & Medical Directors Requires registration to do the program and submission of documentation when each module is completed by dialysis provider

26. Promote Please go back to your facility and encourage your management to participate in this educational safety effort.

27. Promote patient, public, and professional education Maintain a resource library of educational materials Conduct workshops on quality of care concepts Distribute a newsletter to dialysis and transplant facilities Maintain Network website, with QI links Establish partnership and collaborative activities Major disaster coordination Assist patients, family or providers Provide consultation or investigation Complaints/Grievances ESRD Community Information & Clearinghouse/Resource

28. Network Leadership: 3 Face to Face Meetings per Year Board of Directors: 25 to max of 40 members. Term of service is 2 years but can be renewed to a max of 4 years. Medical Review Board: 15 to max of 20 members. Term of service is 2 years but can be renewed to a max of 4 years. Election to be held in November 2007. Terms begin January 2008. 1/3 of BOD and MRB rotate off at each election cycle.

29. CMS Conditions of Coverage for ESRD Facilities Final Rule Published 4/15/08 Highlights of Provisions in the Final Rule Include: Updated CDC guidelines for hemodialysis facilities Updated AAMI water quality guidelines Defibrillators in every dialysis unit Incorporates sections of the 2000 Life Safety Code for fire safety Option for patients to have an advance directive

30. Highlights of Provisions in the Final Rule Continued: Facilities provide written notice 30 days before a patient is involuntary discharged Facilities perform clinical assessment within 30 days, or 13 hemodialysis treatments, of patient starting treatment Home dialysis water purity requirements based on updated AAMI standards Facility-level quality assurance and performance improvement program

31. Minimum qualifications and training requirements for patient care technicians (PCTs) Responsibility of Medical Director for Quality Assessment and Performance Improvement (QAPI) and involuntary transfers or discharges Electronic data collection and reporting The CMS link to the final rule: www.cms.hhs.gov/CFCsAndCoPs/downloads/ESRDdisplayfinalrule.pdf Highlights of Provisions in the Final Rule Continued:

32. Effective Dates New Conditions for Coverage 6 months 10/14/2008 Life Safety Code and Separate room for HBsAg+ patients 300 days 2/9/2009 Certification of technicians hired after 10/4/2008 18 months from hire Certification of existing technicians 24 months 4/15/2010 Governance: Electronic Data Submission As of 2/1/2009, every facility must electronically submit data on all patients, including data on clinical performance measures, to CMS.

33. Thank you for all the good work you do for your patients