2009 Standardized Mortality Ratio Project: Summary Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator ESRD Network 18 July 21, 2009 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 DFRs just received: expect to receive your reports in August Project Timelines: Oct facilities notified Nov 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 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 4 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 Project Summary 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 gm/dl. For year, the Network goal for anemia will be: 52% of patients on ESA therapy having a Hgb between gm/dl. No more than 4% of patients with a Hgb 1.2. This is the Network goal for the 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 top 10 focus areas: Vascular Access Care: Review of vascular accesses to ensure that the correct vascular access is recorded in the patients 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 patients 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 patients 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 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 patients 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 facilitys 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: Review and update your QAPI as necessary The Network will continue monitoring your facilitys SMR for the next 3 years Review your facilitys DFR to ensure the data reported is correct Svetlana (Lana) Kacherova, QI Director Lisle Mukai, QI Coordinator 6255 Sunset Boulevard Suite 2211 Los Angeles CA (323) (323) /Fax