title: Dialysis practices that distinguish facilities with below- versus above-expected mortality.
abstract: OBJECTIVE
  Mortality rates vary widely among dialysis facilities even after adjustment with standardized mortality ratios (SMRs). This variation may occur because top-performing facilities use practices not shared by others, because the SMR fails to capture key patient characteristics, or both. Practices were identified that distinguish top- from bottom-performing facilities by SMR.
  
  
  METHODS
  A cross-sectional survey was performed of staff across three organizations. Staff members rated the perceived quality of their units' patient-, provider-, and facility-level practices using a six-point Likert scale. Facilities were divided into those with above- versus below-expected mortality on the basis of SMRs from U.S. Renal Data Service facility reports. Mean Likert scores were computed for each practice using t tests. Practices that were statistically significant (P ≤ 0.05) and achieved at least a medium effect size of ≥0.4 were reported. Significant predictors were entered into a linear regression model.
  
  
  RESULTS
  Dialysis facilities with below-expected mortality reported that patients in their unit were more activated and engaged, physician communication and interpersonal relationships were stronger, dieticians were more resourceful and knowledgeable, and overall coordination and staff management were superior versus facilities with above-expected mortality. Staff ratings of these practices explained 31% of the variance in SMRs.
  
  
  CONCLUSIONS
  Patient-, provider-, and facility-level practices partly explain SMR variation among facilities. Improving SMRs may require processes that reflect a coordinated, multidisciplinary environment (i.e., no one group, practice, or characteristic will drive facility-level SMRs). Understanding and improving SMRs will require a holistic view of the facility.
authors.affiliation: Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA. bspiegel@mednet.ucla.edu
authors.forename: Brennan
authors.initials: B
authors.lastname: Spiegel
authors.forename: Roger
authors.initials: R
authors.lastname: Bolus
authors.forename: Amar A
authors.initials: AA
authors.lastname: Desai
authors.forename: Philip
authors.initials: P
authors.lastname: Zagar
authors.forename: Tom
authors.initials: T
authors.lastname: Parker
authors.forename: John
authors.initials: J
authors.lastname: Moran
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Solomon
authors.forename: Osman
authors.initials: O
authors.lastname: Khawar
authors.forename: Matthew
authors.initials: M
authors.lastname: Gitlin
authors.forename: Jennifer
authors.initials: J
authors.lastname: Talley
authors.forename: Allen
authors.initials: A
authors.lastname: Nissenson
mesh_terms: D001291:Attitude of Health Personnel; D019985:Benchmarking; D003430:Cross-Sectional Studies; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006268:Health Facilities / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D016014:Linear Models; D008297:Male; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010348:Patient Care Team / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000401:mortality*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology