standardized mortality ratio (smr) project

Standardized Mortality Ratio (SMR) Project

Lisle Mukai, QI CoordinatorESRD Network 18December 2, 2009

Standardized Mortality Ratio (SMR)

The SMR compares the observed death rate in your facility to the death rate that was expected based on national death rates for patients with the same characteristics as those in your facility (Wolfe, 1992).

The SMR indicates whether patients treated in the facility had higher or lower mortality than expected when adjusted for age, race, ethnicity, sex, diabetes, years of ESRD, co-morbidities, body mass index, and population death rates.

Standardized Mortality Ratio (SMR)

The facility’s Standardized Mortality Ratio (SMR) is found in the Dialysis Facility Reports (DFR) and available on the Dialysis Facility Compare website.

These reports are prepared by the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC) for each dialysis facility under contract with the Centers for Medicare & Medicaid Services (CMS).◦Distributed by the Networks


According to the 2009 DFR reports there are 11 facilities within Network 18 that were ranked “Worse Than Expected”.

During this project, facilities will be required to conduct a Root Cause Analysis for their high SMR and develop a QAPI plan to address the facility’s findings. The facility will implement the plan and monitor their progress for improvement.


Inclusion Criteria:◦Facilities with an SMR rated “Worse Than Expected”

Objective:◦All facilities will be required to develop a QAPI

(Quality Assessment and Performance Improvement) Plan utilizing the PDSA model to improve their SMR and implement those plans.

◦Successful completion of the facility’s plan will be based on the development of a process, Policy & Procedure, or program to address identified area(s) for improvement.

SMR Project (continued)

Goal:Each facility will conduct a QAPI to address their SMR based on their identified issue(s) and develop a process, Policy & Procedure, or program and implement those processes.

Timeline:◦September 2009 – May 2010◦Project facilities will be monitored for three

years (2009-2012)

SMR Project (continued)Due dates:

◦Facility Process Review Checklist – due October 13, 2009

◦Facility Manager Acknowledgement Letter – due October 13, 2009

◦Facility Medical Director Acknowledgment Letter

◦QAPI (Quality Assessment and Performance Improvement) Plan – due Wednesday, December 31, 2009

SMR Project (continued)Network Responsibilities:

◦Project Leader ◦Instruct/assist with the QI process◦Distribute templates for RCA and PDSA◦Distribute resources and evaluate their

usefulness◦Provide technical assistance as necessary◦Conduct facility site visits as necessary

SMR Project (continued)

Facility Responsibility:Conduct a root-cause analysis and develop a

QAPI PlanSubmit a copy of your QAPI plan to the

Network

Implement QAPI plan and revise as necessary during the project

Monitor your facility’s progress towards achieving the goal

SMR Project (continued)Identify tools that would be useful for your

facility

Follow project timelines/due dates

Submitting requested documents for the project in a timely manner

Develop a process or Policy & Procedure or to address identified issue(s)Submit a copy to the Network

Quality Assessment and Performance Improvement Plan (QAPI)

494.110: (V626) Condition

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.

Quality Assessment and Performance Improvement Plan (QAPI)

Interdisciplinary Team: (minimum)o Physiciano Registered nurseo Social Workero Dietitian

Quality Assessment and Performance Improvement Plan (QAPI) (continued)

Standard: Program Scope:

1. The program must include, but not limited to, an ongoing program that achieves measurable improvement in healthcare outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.


Standard: Program Scope:

2. The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations.


Standard: Monitoring performance improvement:

The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.

Quality Improvement Process

The process involves:Defining the problemInvestigating through gathering evidenceIdentifying root causesImplementing solutionsMonitoring those solutions to ensure they continue to prevent the original problem.

Rootcauseanalybasics.com

Quality Improvement Process (continued)

Root Cause Analysis (RCA):At its most basic, the process asks three questions, which together provide the framework of a root cause analysis investigation:

1. What was the problem?2. What were the causes of the problem?3. What actions should be taken to

prevent the problem from occurring again? Rootcauseanalybasic

s.com


Root cause analysis can use a variety of techniques to uncover root causes, including cause mapping, change analysis, the Ishikawa fishbone diagram, 5 Whys, and others.

All are designed to analyze the elements affecting a particular outcome to determine the root causes.



Root Cause Analysis Investigations:◦Every cause uncovered by RCA must be

backed up by evidence.◦RCA usually uncovers a system of root

causes.◦RCA uncovers specific causes and effects.◦RCA results in executable, quantifiable

solutions that may be monitored.



Root Cause Analysis Investigations: (continued)

◦RCA does not point blame at any one person or group, but simply identifies a system of causes and effects that lead to and incident.

◦RCA focuses on past events.


Quality Improvement Process(continued)

Fishbone Diagram (aka: Cause and Effect Diagram)

◦The fishbone diagram will help to visually display the many potential causes for a specific problem or effect.


Fishbone Diagram (continued)The Cause-and-Effect diagram can be used

by individuals or teams - most effective by a group.

The team assists by making suggestions of possible causes until no more causes can be suggested.

Once the entire fishbone is complete, a team discussion takes place to decide what are the most likely root causes of the problem.


Fishbone Diagram: (continued)

◦Benefits of a fishbone diagram: It helps teams understand that there are

many causes that contribute to an effect. It graphically displays the relationship of

the causes to the effect and to each other. It helps to identify areas for

improvement.Institute for Healthcare Improvement


5 Whys:Repeatedly asking the question “Why” to peel away the layers of symptoms which can lead to the root cause of a problem.

Although this technique is called "5 Whys," you may find that you will need to ask the question fewer or more times than five before you find the issue related to a problem.

Six Sigma (www.isixsigma.com)


Benefits Of The 5 Whys

Help identify root cause of a problem. Determine the relationship between

different root causes of a problem. One of the simplest tools; easy to

complete without statistical analysis.



Whys And The Fishbone Diagram

The 5 Whys can be used individually or as a part of the fishbone diagram.

The fishbone diagram helps you explore all potential or real causes that result in a single defect or failure.

Once all inputs are established on the fishbone, you can use the 5 Whys technique to drill down to the root causes. Six Sigma

(www.isixsigma.com)

Whys And The Fishbone Diagram


Quality Improvement Process: (continued)

Plan-Do-Study-Act:PDSA is the format the Network uses for developing a QAPI plan.

ACT PLAN

STUDY DO

Quality Improvement Process:(continued)

Quality improvement is a continuous cycle of planning, implementing strategies, evaluating the effectiveness of these strategies and reflection to see what further improvements can be made.

Royal Children’s Hospital Melbourne – Clinical Quality & Safety


PDSA approaches promote action by getting clinicians to reflect and brainstorm strategies that they hope will lead to improvement.

It also promotes evaluation of these changes once the strategies have been implemented.

Royal Children’s Hospital Melbourne – Clinical Quality & Safety


PDSA is a cycle of improvement that involves asking three key questions:

1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in an improvement?

NHS Scotland (www.clinicalgovernance.scot.nhs.uk

Adopted from IHI Website, June 2007

PROJECT: TEAM: (List all members)BACKGROUND: (Summary of facility’s identified problem and description of what the facility has been doing to improve the problem.)

Step 1.PLAN:Plan the test.

What is the objective of this improvement cycle?

What is the goal? (Include a numeric goal to achieve.)

Develop a plan to achieve the goal? (List steps of the plan – this will allow you to identify the step that may need modifying/revising if necessary.)

2 of 3 pagesWhat data sources are needed for the test? (What data sources will you be using to monitor your progress?)

What measures are used to analyze if you are achieving the goal?BASELINE: Measure: (Numerical formula)

Monitoring frequency:

PDSA Template

Step 2.DO:Try out the test on a small scale.

Implement the plan. Document problems and unexpected observations.

Step 3.STUDY:Set aside time to analyze the data and study the results.

Analyze the results and compare the results with your goal.

Step 4.ACT:Determine if the test was successful or the plan needs to be revised.

If the test was successful, how will you implement the plan on a wider scale?

If it was not successful, what needs to be changed based on what you have learned? Should you continue to search for other root causes?


Plan: Set your objective for the project Set goals to achieve (numerical goals and a target date) Develop your plan on how you will improve your identified problem Include a plan for collecting data List data sources you will use to monitor your progress for the project


Plan (continued): Write out the measure you will be using to analyze if you are achieving your goal. (numerical formula)

Example: # of prevalent patients using AVF as primary access = AVF rate Total # of patients at the facility


Plan (continued):

Note the frequency in which you will conduct measurement of your progress

Note your baseline for comparison towards your goal


Do: Implement your plan Document problems and unexpected observations of your plan

Study: Analyze the results and compare it to the goal This analysis should be conducted with the interdisciplinary team.


Act: Is your plan successful?

How will you ensure continued improvement?

If it wasn’t successful, what needs to be changed based on what you have learned?

Should you continue to search for other root causes?

Plan-Do-Study-Act (PDSA) (continued)

The PDSA cycle is a continuous cycle. It allows you to frequently assess your plan and make revisions as necessary to achieve your goal.

Your plan should be reviewed at least monthly and/or when you realize that your strategy or activity is not working.


Note your progress on your form so that you have a record of the strategies/activities you’ve attempted and results of those attempts as well as the revisions you have made to improve your plan.

Accuracy Issues (based on Medicare Billing data and may not capture 100% of patient population)

DFR includes deaths up to 60 days after transfer out from the facility

SMR calculation depends on the accurate completeness of the form by facility staff (results can be a mismatch between 2728 initial data and DFR billing data)

Barriers to Facility Improvement Related to SMR

UM-KECC

Common Barriers and Issues Identified by Network 18 Facilities in the Past:

High infection rate due to high catheter rate

Medical Insurance Issues (Emergency medical only)

Under-reporting of co-morbidities on the 2728 CMS Medical Evidence Forms

Under-reporting of the number of patients with diabetes as a primary cause of ESRD

Variables That May Affect SMRUnique variables:

◦Geographic location◦Patient population characteristics◦Small facility size◦Admission of more acutely ill vs. stable patients◦Other factors

Clinical Indicators◦Adequacy of dialysis◦Hemoglobin◦AVF utilization◦Serum Albumin

Facility Process Review Checklist

Facility Process Review Checklist

Facility Results: NOT MET or IMPLEMENTED◦At least 92% of patients in the facility have a Kt/V

> 1.2 or at least 89% of patients in the facility have a URR > 65%

◦Less than <10% of patients in the facility have a catheter as a permanent vascular access.

◦At least 50% of patients in the facility have an AVF as a permanent vascular access.

◦Facility has a formal vascular access monitoring/ surveillance program

Measures Assessment Tool

Network 18 Clinical Indictor Goals

Network 18 Clinical Indictor Goals

Adequacy: % of Pts with mean URR > 65% = 89%% of Pts with mean spKt/V > 1.2 = 92%% of Pts with mean weekly Kt/V > 1.7 (PD) = 80% (CMS goal)

Anemia:% of Pts with mean Hgb 10-12 g/dL = 52%% of Pts with mean Hgb < 10 = < 4%

Network 18 Clinical Indictor GoalsNutrition:HD = % of Pts with mean serum Albumin > 3.5/3.2 g/dL (BCG/BCP) = 85%PD = % of Pts with serum Albumin > 3.5/3.2 g/dL (BCG/BCP) = 65%

Vascular Access: (CMS AVF Goal = 66%)% of Pts with Prevalent AVF = 57.8% (by March 31, 2010)% of Pts with Catheter > 90 days = < 10%% of Pts with AVGs = < 24%

Areas of Concentration from Previous Project Facilities:

Monitoring of co-morbid conditions◦Ensuring that all co-morbid conditions are reported

accurately on the patient’s 2728 form and noted on the patient’s history

Tracking and reporting accurate cause of death on the 2746 forms.◦Trending mortality

Monitoring hospitalization◦Tracking of reasons for hospitalization◦Tracking infection rates


Vascular Access◦Catheter reduction◦Reducing access infections◦Monitoring clotting episodes◦Increasing AVF usage

Vaccinationso Tracking all immunizations

Patient safety (facility-specific issues)


Monitoring patient clinical outcomes◦Anemia◦Adequacy Treatment time

◦Nutrition◦Calcium ◦Phosphorus


General business operations◦Adequate staffing◦Sufficient time to perform tasks/duties

Summary:Facility to conduct a root-cause analysis of why

they have a high SMR rate.Develop a Quality Assessment Performance

Improvement (QAPI) Plan to improve SMR rating signed by the Medical Director ◦Submit a copy to the Network by December 31,

2009.Implement and monitor progress of your QAPI

plan.Submit supporting documents upon requestBy the end of the project (May 2010) develop a

P&P or process that addresses identified issue(s).

Project Communication:To communicate more efficiently with you

about this project and to be more eco-friendly, we are creating a listserv of all the facilities in this project.

In the past, we have had e-mail delivery problems with facility firewalls, please ensure you are able to receive e-mails from us about the project. Consult with your IT Department to assist you.

Lisle Mukai, RNQuality Improvement Coordinator

ESRD Network 18323-962-2020

[email protected] 18 website: www.esrdnetwork18.org

mailto:[email protected]

http://www.esrdnetwork18.org/

standardized mortality ratio (smr) project

Documents

high smr

dialysis facility reports

facility manager

facility wolfe

project facilities

smr project continuedgoal

facilitys plan

dfr reports