Project Guidelines

IPRO ESRD Networks are tasked by the Centers for Medicare and Medicaid Services (CMS) to work with facilities to increase hepatitis B (HBV) and pneumococcal pneumonia vaccination (PPV) rates to 60% or greater and ensure that vaccinations are recorded correctly in CROWNWeb.

Dialysis patients are at greater risk for complications related to hepatitis B and pneumococcal pneumonia. Despite the length of time these vaccinations have been available in the U.S., and the high risk to this population, a low percentage of patients are receiving them.

Based on CROWNWeb data in 2016 overall rates for the PPV and HBV vaccinations in New York were 81.16% PPV and 63.60% HBV. Hepatitis B and pneumonia can lead to serious complications and death in the dialysis population. The IPRO ESRD Network program will work with facilities in its service area that have low rates of hepatitis B (HBV) and pneumococcal pneumonia vaccinations to identify barriers and implement strategies to increase rates of pneumococcal pneumonia and hepatitis B vaccinations at participating facilities.

Target facilities complete a root cause analysis (RCA) that will be assist them and the Network with creating individualized and systematic Plan Do Study Act (PDSA) Plans for improving rates of pneumococcal pneumonia (PPV) and hepatitis B (HBV) vaccinations. In some cases this is a clinical practice improvement, and in others it is a CROWNWeb data reconciliation improvement project.

Goal: Facilities must increase their vaccination rates to >60% for both the pneumococcal pneumonia (PPV) and hepatitis B (HBV) vaccinations measures to graduate from the project. If facilities do not reach this goal, they will continue in the project during the following year.

Timeline: Facilities are selected and notified of their participation in January. The Network will work with the facilities to implement interventions. The re-measurement will be completed in September based on July data submitted in CROWNWeb.

Facilities will be notified in October if they have met the goal to graduate or will continue in the project during the next year. Facilities not meeting goal should continue to implement interventions and strategies regardless of the measurement period to maximize their ability to graduate in future years.

Facility Selection: Facilities in the lowest quintile for both vaccination rates were selected to participate in the project (maximum 25 facilities).

Baseline Data: The QIA baseline data (September 2016) was provided by the ESRD National Coordinating Center (NCC) from the facility submitted information available in CROWNWeb.

Re-Measurement Data: Vaccination data for this QIA will be extracted from facility monthly CROWNWeb data, and will be provided to the Network by the ESRD National Coordinating Center (NCC.)

Goal and Timeline: Facilities must create an RCA of barriers and implement activities (either clinical or data reconciliation) to achieve at least 60% vaccination rates for each measure.

Tools and Resources

CDC Vaccination Guidelines for Patients on Dialysis

Vaccination Trifold created by the network to educate patients on the need of vaccinations. Trifold also available in Spanish. Contact the Network for printed materials.

Vaccination RCA - Root Cause Analysis

Key Staff Contact Form

Tips for Entering Vaccination Data into CROWNWeb pdf

Project Webinars:
1/31/2017 Vaccination QIA: Project Kick off Slides
5/17/2017 Vaccination QIA: Spring Update Slides

Vaccination QIA

For more information:

Anna Bennett
Education Coordinator
516-209-5474
abennett@nw2.esrd.net