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  • 1. 2009 Standardized Mortality Ratio Project: Summary Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 July 21, 2009
  • 2. SMR Project: Inclusion Criteria for Participating Facilities
    • SMR rated “Worse than expected” (2008 DFR data) – 26 facilities
    • State Surveyors review DFRs before visiting facilities
    • SMR information is available on the Dialysis Facility Compare website at www.medicare.gov
    • 2009 DFRs just received: expect to receive your reports in August 2009
  • 3. Project Timelines:
    • Oct. 2009 – facilities notified
    • Nov. 2009 – WebEx session
    • Nov. - Dec. – Collection of the MD letters, Facility Process Checklists, RCA, and action plans (PDSA)
    • Jan. – May 2009 – project implementation
    • Feb.– March 2009 – Network follow-up (supportive documentation)
  • 4. Network Role During the Project:
    • Project Leader
    • Supplied the templates for RCA & PDSA
    • Supplied facilities with tools and knowledge
    • Periodically monitored and provided feedback
    • Conducted phone interviews to obtain facility-specific data
    • Chased you for data & documentation   
    • Assisted your facility to stay in compliance with the QAPI program requirements
  • 5. V626 QAPI Condition Statement
    • The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team...
    • … The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS
  • 6. Project Summary
  • 7.  
  • 8.  
  • 9. Top 10 Processes identified by facilities
    • 1. Process #8: At least 85% of patients in the facility have hemoglobin above 11gm/dl
      • The current standard for this indicator is Hgb between 10-12 gm/dl.
      • For 2009-2010 year, the Network goal for anemia will be:
        • 52% of patients on ESA therapy having a Hgb between 10-12 gm/dl .
        • No more than 4% of patients with a Hgb <10 gm/dl
  • 10.
    • 2. Process # 11: Less than 10% of patients in the facility have a catheter as a permanent vascular access.
    • Network & CMS goal is <10% of patients having a catheter greater than 90 days
      • Process # 4: Physicians participate in patient care meetings on a regular basis, ensuring that all patients are reviewed at least quarterly.
      • New Conditions for Coverage (494.90)
  • 11.
    • 4. Process #16: Facility staff accurately indicates cause of death when completing 2746 Death Notification forms for deceased patients.
    • Process # 12: At least 50% of patients in the facility have an AVF as permanent vascular access.
        • NW prevalent AVF goal for 2009-2010 = 57.8%
  • 12.
    • 6. Process # 15: Facility staff reports all co-morbidities when completing 2728 CMS Medical Evidence Forms for new ESRD patients.
    • 7. Process # 9: At least 88% of patients in the facility have URR > 0.65 (65%) or Kt/V > 1.2.
        • This is the Network goal for the 2008-2009 year
        • PD goal = 88% of patients with Kt/V > 1.7
  • 13.
    • 8. Process # 14: Facility Nurse Manager has sufficient time to complete all administrative tasks and requirements (e.g. Network forms).
    • 9. Process # 1: Physicians see patients and review records/orders at least weekly (new & unstable patients) and at least monthly (stable or long-term patients).
  • 14.
    • 10. Process #17: Facility has a formal vascular access monitoring/intervention program.
    • Per the Interpretive Guidelines:
        • “ Monitoring ” strategies include physical examination of the vascular access.
        • “ Surveillance ” strategies include device-based methods.
  • 15.  
  • 16. Summary of Strategies for the top 10 focus areas:
    • Vascular Access Care:
    • Review of vascular accesses to ensure that the correct vascular access is recorded in the patient’s electronic records and facility tracking logs.
    • Staff education on vascular access care
    • Patient & family education on vascular access care
  • 17.
    • Develop communication with physician regarding access placement prior to hospital discharge.
    • Engage nephrologists & surgeons into the Fistula First program
    • Find a good vascular access surgeon
    • Use the Vascular Access Centers for vessel mapping, follow-up, and interventions.
    • Develop & implement a catheter reduction program – addressing both prevalent & incident patients.
  • 18.
    • Complete/Accurate 2728 Forms:
    • Have the physician or the Clinical Manager review forms prior to submitting form to the Network
  • 19.
    • Complete/Accurate 2746 Forms:
    • Have the physician or Clinical Manager review forms prior to submitting form to the Network
    • AA will keep a binder of all 2746 forms and keep a log for all causes of death
    • Develop & implement a mortality tracking report
  • 20.
    • Reporting of Co-morbidities:
    • Review of medical records for co-morbid conditions (H&P) when planning care
    • Have physician review all co-morbid conditions prior to signing 2728 forms
    • Have physician include co-morbid conditions on the patient’s progress notes
  • 21.
    • Catheter Reduction:
    • Implementation of a catheter reduction program – addressing prevalent & incident patients
    • Nephrologist develop a relationship with surgeons and explain the importance of vascular access care with emphasis on AVFs
  • 22.
    • Review of Clinical Indicators:
    • Review of monthly lab results by the interdisciplinary team
    • Trend facility data for each indicator – assess need for improvement
    • Monitor outcomes by physician group and have the Medical Director maintain communication with the group regarding their statistics
    • Distribute physician or physician group QA reports of those patients that fall below the goal(s)
  • 23.
    • Anemia Management:
    • Identify patients with Hgb < 10 and develop Plan of Care
    • Protocol changes to reflect the new Conditions for Coverage
    • Designate hours for the Anemia Manager to perform duties
  • 24.
    • Monitoring of Infections:
    • Decrease catheter rate - Educating patients & families about benefits/disadvantages of catheters
    • Develop & implement an infection control log to track the types of infection, actions/interventions taken, date of resolution, and trending of types of infection and frequency of events
    • Monitor staff adherence to infection control policies
    • Encourage and remind patients to wash access prior to treatment
  • 25.
    • Staff Education:
    • Hold in-services
    • Patient Education:
    • Staff to educate patients on compliance with dialysis prescription, diet, and vascular access care – focused education for specific issues
    • Social worker to check/assess all diabetic patients to see if they need more diabetes education and refer them to a diabetic center
  • 26.
    • Patients will be given a report card (phosphorus, potassium, etc.) and it will be discussed with the dietitian on a monthly basis
    • Dietitian maintains communication with the family and/or nursing home regarding the patient’s diet
    • Lobby poster displays regarding patient issues the facility would like to address (i.e. fluid restricitons)
  • 27.
    • Facility host a nutritional day –
    • Example: “Cheese Alternative Tasting Day” to provide a sampling of rice-based and soy-based cheeses in a variety of flavors to educate patients on cheese alternatives available
  • 28. Other Focus Areas and Strategies
    • Hospitalization:
    • Develop hospitalization tracking log – track suspected/actual causes for admission
    • Medical Director/Nephrologist to follow-up on all patients hospitalized > 4 days
    • Review of newly admitted unstable patients weekly with focused discussion on the patient’s needs
  • 29.
    • Review of patient assessment & Plan of Care monthly on all unstable patients
    • Review hospital admission & discharge reports to establish correct causes of admission, procedures performed, and medication changes
    • Patient education regarding good hygiene and prevention of illness
  • 30.
    • Vaccination:
    • Designate a specific individual to oversee the facility’s vaccination program (monitor progress and initiate vaccination orders)
    • Management:
    • Improve staff/management retention through efficient training
    • Designate managers to oversee specific clinical areas (anemia, vascular access, infection, adequacy, etc.)
  • 31.
    • Hold QAPI meetings at least monthly to discuss patient issues and concerns and facility issues and concerns
    • Improve documentation, tracking and timely/accurate data submission
  • 32. Next steps of the project:
    • Review and update your QAPI as necessary
    • The Network will continue monitoring your facility’s SMR for the next 3 years
    • Review your facility’s DFR to ensure the data reported is correct
  • 33. Svetlana (Lana) Kacherova, QI Director [email_address] Lisle Mukai, QI Coordinator [email_address] 6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028 (323) 962-2020  (323) 962-2891/Fax  www.esrdnetwork18.org