Conference: Creating a culture of quality: Developing the infrastructure to meet quality improvement requirements
March 16
Baltimore, Md.
Organizer: The Forum of ESRD Networks

Running a business effectively means making sure all parts of your operation are operating smoothly. It's no different in health care: to deliver treatment to patients equitably, everyone must be doing their job.

What happens when they don't? Dialysis providers have multiple ways of identifying poorly performing clinics. Last Wednesday, I attended a special meeting in Baltimore organized by the National Forum of ESRD Networks focused on identifying dialysis clinics that aren't keeping up. This is the second of two posts discussing the outcome of the meeting.

Tracking data is one effective way of determining outcomes, and a barometer on identifying dialysis clinics that are underperformers. Under the Medicare-driven Quality Incentive Program that takes effect in January, dialysis clinics can lose up to 2% of their bundled payment if they don't meet certain quality outcomes in adequacy and anemia management. More than likely, those basic performance measures will have company in the years to come as Medicare looks for ways to reduce costs and improve quality in the ESRD Program.

The Quality Conference organized by the Forum of ESRD Networks last week offered a place to talk out loud about some of the problems that providers face in meeting those goals.

In a panel discussion called, "Identifying facilities that are most at risk," speakers from Dialysis Clinic Inc., Fresenius Medical Care, DaVita Inc., and three ESRD Networks talked about identifying the signs that clinics were in trouble.  Much of that had to do with setting up checklists and tracking practices and events that lead to poor performance. Examples included:

• Are the clinics tracking and implementing vaccinations?
• Are they applying consistent approaches to fluid management?
• Are they identifying patients who shorten their treatments, and making efforts to reduce or eliminate these bad habits?
• Are they tracking the percentage of hospitalizations, which not only can lead to exposing patients to other illnesses but also can cut treatment revenue? Clinics should be identifying trends in what is causing hospitalizations and minimize reoccurrences.

Also, look for:

• timely completion of patient care plans
• repeated staff turnover at the clinic

If they are using a high number of agency nurses and patient care technicians, that could be an indicator of problem. Turnover also impacts a patient's view of the quality of care they are receiving; it could affect their motivation to be compliant.

Then there is the 'gut' feeling: watching the renal team work together. Are they providing good patient care—consistently? Following basic protocols? Likewise, evaluate the center's leadership. Look at whether medical directors are having difficulty handling the role of improving quality, speakers said.

Networks have systems in place for tracking and trending facility outcomes; poor performing facilities are identified and evaluated in a Medical Review Board meeting. Network 9/10, for example, has a facility profiling system that identifies poor performing clinics. The MRB looks at reports once a year identifying facilities in trouble, based on the composite score.  Points are accumulated based on performance on a range of 0-50 points. Facilities that garner 40 to 50 points may get a Network site visit, particularly if they show poor performance consistently over two to three months.

Sometime quality program are directed by good staff, but outcomes suffer because of implementation issues. Gina Randolph, RN, MSN, MBA, who is responsible for clinical and technical services nationwide for DaVita, said barriers to the company's 'Cathaway' catheter reduction program include 31% of patients with catheters who refused to give them up.

The good news: 77% of DaVita patients have permanent access placed by day 90. The company uses vascular access managers to monitor patient progress, and even sometimes simple things work, such as giving a patient a congratulatory greeting card when they receive their first needle stick on a new fistula.  It reinforces to them that they made the right decision. The card is practical, too: It includes noises as to how your fistula should sound when healthy.

In a follow-up presentation to identifying facilities that are at risk, Doug Johnson, MD, vice chairman of the Board for Dialysis Clinic Inc., and Pam Havermann, RN, director of quality management and education for DCI, reviewed steps the company took to improve performance at 19 dialysis clinics identified as under-performers. Plans of correction were written for each facility. Targets and timelines were set, and grades of 1-3 were assigned as clinics improved.

Patience is important, said Havermann: "It can take four to five months before you start seeing real improvement." In some cases, staffing had to change, including removal of administrators and one medical director.

After one year, five of the 19 clinics came off the list of poor performers. "We have to step back and give them the tools; the clinic has to do the work," Havermann said.  

You also need to evaluate management staff honestly. "There are some people you like, and you want them to do well … but they might not be able to take you there" and bring the facility up to a high performing level, she said.

Ultimately, changing culture in a clinic as a way to improve outcomes has its limits.

"You can't change behavior; you can influence behavior," said nephrologist Peter DeOreo, in concluding remarks. Improving quality can mean changing—or creating—a culture that focuses on teamwork. Sometimes, big changes are needed to get the job done.

The presentations from the conference are available from the Forum of ESRD Network's website.