Instructions

WARNING: DO NOT USE ANY PATIENT-SPECIFIC INFORMATION IN THIS SURVEY (NAME, DATE OF BIRTH, SOCIAL SECURITY NUMBER, ETC.). THIS WOULD BE CONSIDERED A SECURITY INCIDENT DUE TO PATIENT CONFIDENTIALITY AND AS SUCH WOULD BE REPORTED TO CMS.

A root cause analysis (RCA)  is a quality improvement tool used to identify any causes or reasons behind a specific issue. Completion of a thorough and credible RCA will assist you in the development or updating of an existing facility improvement action plan.   The Network recommends you complete this RCA with the input of your facility's vascular access team and patient's perspective.
Definition of long-term catheter (LTC) utilization is when a patient has dialyzed with a catheter for 90 or more days, with or without a maturing fistula, with or without a healing graft.
 
Please read the description of the RCA categories below before starting the survey:
  • Patient-Related Factors: examples include comorbidities, directed donor transplant workup in progress, peritoneal dialysis planned, patient refuses, patient cancels or is no show for appts., fear of needles/surgery/body changes, lack of knowledge about permanent vascular access options and/or catheter risks and complications, transportation 
  • Nephrologist-Related Factors: examples include does not evaluate patient for permanent access, referral issues, lack of timely referral to VA surgeon, does not initiate or activate patient's vascular access plan; does not educate patient about risks of LTC, lack of communication between nephrologist and surgeon 
  • Surgeon-Related Factors: examples include surgeons not seeing new dialysis patients until 90 days after surgery, payment\reimbursement  issues, lack of availability of VA surgeons,  lack of surgical training/experience in placing permanent vascular accesses
  • Dialysis Center Factors: examples include lack of tracking system for monitoring catheters,  lack of knowledge about vascular access guidelines, staff preference for catheters (i.e., easier to initiate treatment, comfort levels, faster to access, etc.), lack of skill in cannulating AVFs/AVGs, staff turnover, inadequate staffing number/mix, no designated VA Coordinator or VA manager at facility, LTC not considered a QI priority, organizational culture
  • External Factors: example includes hospital discharge of patients with catheters with no access plan in place
1. Select the root cause or root causes for each category. Multiple selections per section are allowed.
2. Describe any root causes NOT listed under each category in the Other (comment) field.
 

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* 1. Provide first and last name of person completing this survey

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* 2. Provide name of facility

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* 3. Provide 6-digit CMS provider number (CCN#, begins with a 45 or 67)

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* 4. What are Patient-Related Factors that you think are attributable to high LTC utilization? Make sure patient feedback is obtained. This is an opportunity to work with your FPRs or Patient Champion.

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* 5. What are Nephrologist-Related Factors that you think are attributable to high LTC utilization?

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* 6. What are Surgeon-Related Factors that you think are attributable to high LTC utilization?

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* 7. What are Dialysis Facility-Related Factors that you think are attributable to high LTC utilization?

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* 8. What are External-Related Factors that you think are attributable to high LTC utilization?

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* 9. Completion of this root cause analysis was easy to do on-line.

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* 11. Any additional thoughts or comments you would like to provide about this process? i.e., offer potential solutions to overcome any of the barriers you indicated through this assessment.

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* 12. How many undocumented immigrants does your facility currently treat with in-center hemodialysis? An undocumented immigrant refers to individuals present in the U.S. without proper authorization.

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* 13. If you answered that your facility provides in-center hemodialysis to one or more undocumented patients, how many undocumented patients dialyze through a long-term catheter (catheter >=90 days)? Please enter just a number.

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