Facilities Involved in Vaccination QIA

Project Guidelines

Project Agreements/Contracts due back to the Network by February 18, 2017.

IPRO ESRD Networks will be implementing CMS designated activities with facilities chosen for this activity to increase rates of pneumococcal pneumonia and hepatitis B vaccinations at the facility level. Facilities will be provided with root cause analysis (RCA) templates that the Network will review with the project lead to develop a Plan Do Study Act (PDSA) Plan for improving rates of pneumococcal pneumonia and hepatitis B vaccinations.

AIM:  To improve vaccination rates in participating facilities by 10% of low-performing facilities (maximum 25 facilities)

Baseline: The project will have September 2016 baseline provided by the NCC with re-measure in September 2017.

Goal and Timeline: Facilities must increase their Hepatitis-B and pneumococcal vaccination rates by 3% point increase over baseline. Develop RCA of barriers and achieve at least 60% vaccination rates for each measure.

Tools and Resources

CDC Vaccination Guidelines for Patients on Dialysis

Notification letter - Participation agreement from the Network

NW1 Vaccination Trifold - Created by the Network to educate patients on the need of vaccinations. Trifold also available in Spanish. Contact the Network for materials.

Vaccination RCA  - Root Cause Analysis

Personal Health Record -  Created by the Network to assist patients to better manage their health and medications. Patients are to take this Personal Health Record with them to wherever they go, including ALL doctor visits and future hospitalizations.

Initiative Contacts:

Agata Roszkowski, LMSW
Patient Services Director

Cheryl Pettway
Community Outreach Coordinator