Project Guidelines

IPRO End Stage Renal Disease (ESRD) Network of New England would like to notify facilities of a national initiative from the Center for Medicare & Medicaid Services (CMS) to reduce the rate of all bloodstream infections by 50% of the 2016 rate to insure better health for people in the United States living with ESRD.

Infections are the second leading cause of death in patients with end-stage renal disease (ESRD). The cause for a majority of these infection is catheter- related blood stream infection. As a result, CMS has developed a three part project to ensure safety and a high level of quality care to all ESRD patients.

The Network will be working with 50% of facilities who had the highest BSI rate reported to the National Health and Safety Network (NHSN) during the first and second quarters of 2017.

A priority of the Network is to serve as a resource to both dialysis patients and professionals throughout project activities. Open communication about existing processes, barriers, and successes is encouraged. Network staff members are interested in supplementing resources for what is working in your facility, not adding additional burden. However, in order to assess barriers, and identify how the Network can effectively meet needs of the community, completion of the ACTION REQUIRED activities (at the bottom) is essential for success of the project.

CMS Inclusion Criteria: Your facility has been selected to participate in this Qalitive Improvement Activity (QIA), based on the semi-annual pooled mean rates reported in NHSN for your facility during the baseline period (January through June 2017).

All facilities that have a 15% or greater long-term catheter use rate as of June 2017 will also be required to participate in activities to reduce the use of LTCs.

All facilities in this project are being encouraged to enroll in a healthcare information exchange platform.

Project Goals: Participating facilities shall demonstrate a 20% or greater reduction in the semi-annual pooled mean rate reported in NHSN for the facility from baseline to re-measurement (January through June 2018).

All facilities in this QIA with a LTC rate greater then 15% are required to demonstrate a minimum of a 2% rate reduction.

Project Interventions

BSI Rate Reduction Activities

  • Implement CDC core interventions
  • Perform root cause analysis on identified barriers
  • Complete NHSN training
  • Partner with the CDC Making Dialysis Safer Coalition
  • Appoint a patient ambassador
  • Training patient to perform hand hygiene audits

LTC Rate Reduction Activities

  • Appoint a Vascular Access Coordinator
  • Establish peer-to-peer mentoring
  • Tracking patient with LTC
  • Developing a relationship with Vascular Surgeons groups

We Want to Hear from YOU!

Please contact the Quality Improvement Department if you have questions, comments, or specific barriers that you would like to address. Let us know if you have identified any best practices that you would like to share with the community.




  • Talk with dialysis team members and patients to identify root causes of barriers to increasing utilization of home dialysis.
  • Talk with dialysis team members and patients to identify root causes of barriers decreasing LTC use


Attend: Join us for the Patient Safety: Healthcare-Associated Infections QIA Kick-Off Webinar to be held on Thursday, February 15, 2018 from 1:00-1:30 PM. Project requirements, activities to augment current process, and Q&A session will be available during this webinar.


  • Network BSI QIA Kick- Off call: Slide Deck
  • January's National Coordinating Center BSI QIA Learning and Action Network call recording

Tools and Resources



Provider Audit Tool:

Network Newsletters

For more information:

Sarah Keehner, RN, BSN, CNN
Quality Improvement Director

Quality Improvement Coordinator