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2009 Standardized 2009 Standardized Mortality Ratio Project: Mortality Ratio Project: SummarySummary
Svetlana (Lana) Kacherova, QI DirectorLisle Mukai, QI CoordinatorESRD Network 18July 21, 2009
SMR Project: Inclusion Criteria SMR Project: Inclusion Criteria for Participating Facilitiesfor 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
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Project Timelines: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)
Network Role During the Network Role During the Project: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
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V626 QAPI Condition V626 QAPI Condition StatementStatement
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
Project SummaryProject Summary
Top 10 Processes identified by Top 10 Processes identified by facilitiesfacilities
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
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
2. 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)
4. Process #16: Facility staff accurately indicates cause of death when completing 2746 Death Notification forms for deceased patients.
3. 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%
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
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).
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.
Summary of Strategies for the Summary of Strategies for the top 10 focus areas: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
• 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.
Complete/Accurate 2728 Forms:• Have the physician or the Clinical Manager
review forms prior to submitting form to the Network
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
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
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
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)
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
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
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
• 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)
• 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
Other Focus Areas and StrategiesOther 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
• 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
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.)
• 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
Next steps of the project: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
Svetlana (Lana) Kacherova, QI [email protected]
Lisle Mukai, QI [email protected]
6255 Sunset Boulevard Suite 2211 Los Angeles CA 90028(323) 962-2020 (323) 962-2891/Fax www.esrdnetwork18.org