Facilities Involved in QIA

Project Guidelines

Project Agreements/Contracts due back to the Network by March 6, 2017

IPRO ESRD Network of New England is implementing CMS designated activities to decrease rates of hypercalcemia 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 rates of hypercalcemia. The project will be conducted beginning in March of 2016, and will end when the facility reaches either a 25% relative improvement in rates of hypercalcemia or when the facility exceeds the QIP threshold for this QIP measure.

AIM:  Impact 10 or more Network facilities with the poorest performance on the QIP measure Hypercalcemia. Requirement is to maintain 10 participating facilities throughout the project period.

Baseline: Baseline is November 2015 - October 2016; variable for new facilities. Re-measure will be rolling a three month average of uncorrected serum calcium >10.2 mg/dl.

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.

Tools and Resources

Notice of Participation - The Network will provide a notice of participation in this activity, as well as a template for evaluating the root cause of hypercalcemia

 RCA Template - Facilities will use the provided RCA template to review hypercalcemia rates with the interdisciplinary team during QAPI meetings. Follow up with the

NW1 Hypercalcemia Patient Poster - created to help patients to assist with dealing with hypercalcemia. Poster is also available in Spanish. Please contact the Network for supplies.

Payment Year (PY)  2018 Technical Measure Specifications - Link provided by CMS

Sarah Keehner, RN, BSN
Quality Improvement Director

Heather Camilleri, CCHT
Quality Improvement Coordinator