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