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 www.medicare.gov
 2009 DFRs just received: expect to receive
your reports in August 2009

2
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 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 facilityspecific data
Chased you for data & documentation   
Assisted your facility to stay in compliance with
the QAPI program requirements
4
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

5
Project Summary
18
Top 10 Processes Least Implemented by
Facilities
26 Project Facilities
16
14
Number of Facilities
12
10
8
6
4
2
0
Process 8
Process 11
Process 4
Process 16
Process 12
Process 15
Process 9
Process 14
Process 1
Process 17
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
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
3. 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.
5.
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 comorbidities 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 20082009 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 devicebased methods.
Top 10 QAPI Focus Areas
8
26 Project Facilities
7
Number of Facilities
6
5
4
3
2
1
0
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
•
•
•
•
•
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 Strategies
Hospitalization:
• Develop hospitalization tracking log –
track suspected/actual causes for
admission
• Medical Director/Nephrologist to followup 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:
•
•
•
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 Director
[email protected]
Lisle Mukai, QI Coordinator
[email protected]
6255 Sunset Boulevard  Suite 2211  Los Angeles  CA  90028
(323) 962-2020  (323) 962-2891/Fax  www.esrdnetwork18.org