Definition (3)

1. General: Cooperative arrangement in which two or more parties (which may or may not have any previous relations) work jointly towards a common goal.

2.Knowledge Management (KM): Effective method of transferring ‘know how’ among individuals, therefore critical to creating and sustaining a competitive advantage.

Collaboration is a key tenet of KM.

3. Negotiations: Conflict resolution strategy that uses both assertiveness and cooperation to seek solutions advantageous to all parties. It succeeds usually where the participants’ goals are compatible, and the interaction among them is important in attaining those goals.


The new Centers for Medicare & Medicaid Services’ core survey for the End-Stage Renal Disease Program encourages collaboration of the surveyor, patients, and providers. This ESRD survey process is the agency’s first Survey and Certification Quality Assurance Efficiency and Effectiveness (QAEE) initiative. The initiative uses this survey process to focus available resources through inspection themes and threads in areas pertinent to patient safety and quality of care. This collaboration among surveyors, organizational teams, and patients is intended to foster a patient-centered approach and safety.

New survey approach

The new core survey was developed, piloted among dialysis providers, and fine-tuned in 2012. Feedback from the community was featured in the online NN&I article, “New core survey getting positive feedback from renal community” in September 2013.

There are three themes in the core survey process:

Data use. Facility-specific data is used to identify practices and outcomes potentially needing improvement. This data is reviewed by the inspectors prior to on-site surveys.

Infection prevention and control. Infections are the second leading cause of death in dialysis patients. The development and effectiveness of a comprehensive facility infection control program will be reviewed as part of every survey.

Quality assurance and performance improvement. This is the most important program in a facility. It must be functional and robust to effectively address patient safety and quality of care.

Additionally, three threads run throughout the Core Survey:

Culture of safety. A systemic facility culture that encourages and supports open communication and reporting of errors and potential errors. Surveyors will interview patients and all levels of staff to determine if a culture of safety is present and supported by the Governing Body.

Safety of dialysis delivery. The surveyors take a focused look at the technical aspects of dialysis treatment and the procedural operations. This includes a careful review of water treatment, dialysate preparation, and machine maintenance. The Core Survey Field Manual lists critical elements in each of these areas that have the potential to impact patient safety.

Patient voice. Surveyors interview patients to determine if the facility staff listens to the individual patient about his/her care.

Facility focused

Each survey evaluates the individual facility. The surveyors observe care, interview staff and patients, and review clinical and operational records to determine if the facility staff is qualified, knowledgeable, and equipped to provide safe care. The facility should perform self-surveys routinely to monitor regulatory compliance. An article in NN&I in October 2010 titled “Getting your clinic ready for a facility survey” will assist with a basic review.

Surveyors will be doing some homework prior to visiting your facility. They will review your latest Dialysis Facility Report (DFR), noting how your facility ranks on the various patient outcomes. If your facility outcomes fall below the national averages, they will make note of those low performing areas as potential focus areas. Their next contact will be your local ESRD Network to find out about any quality concerns, such as involuntary discharges, transfers, and patient complaints. They will also look for trends in the state records regarding patient/staff complaint allegations and last survey citations.

Getting ready for a survey

There are some pre-survey preparation tools to prepare the dialysis staff

  1. Obtain an ESRD Core Survey Field Manual Version 1.6.  Go to Look for the “Dialysis” button on the left side of the home page. After clicking on the link, scroll down to the Downloads section of the page and #3 & #4 is the ESRD Core Survey Field Manual Version 1.6 and Surveyor Laminates.
  2. Become familiar with the “Outline of ESRD Core Survey Process” Version 1.2, Manual Tab 2.
  3. Keep an updated Measures Assessment Tool (MAT); Version 2.3, Manual Tab 2.
  4. Complete a draft ESRD Application and Survey and Certification Report CMS-3427, Manual Tab 3.
  5. Use your latest DFR to complete a draft ESRD Core Survey Data Tools, Fiscal Year 2014, pgs. 1-8, Manual Tab 3. [Pages 5-7 are the key to the data driven survey process.]
  6. Complete an internal Personnel, Health, and Medical Staff file review spreadsheet.

Environmental 'flash' tour

Surveyors start each survey with a brief introduction and explanation of the purpose of their visit, along with time lines. If you have completed all the paperwork listed above, you will be ahead of the game.

Next, they begin a “flash” tour. This is to observe patient care-related areas for any immediate concerns about patient safety. All environmental areas (patient care, water treatment/dialysate preparation, reuse and home training), equipment, and maintenance or infection control hazards will be observed during this “flash” tour.

This tour will include at least three dialysis stations. The surveyor will observe ongoing patient treatments and the availability of emergency and evacuation equipment. If any safety concerns are noted, this could be a trigger for possible citation. As defined in the Core Survey Field Manual, “triggers” indicate the presence of adverse conditions/situations and/or deficient practice. When the surveyor identifies a trigger during the ESRD Core Survey activity, it means that a citation may be indicated or more comprehensive investigation into that area should be conducted to determine if and what level of citation is indicated. The Core Survey manual includes a detailed list of triggers with the associated V tag; each trigger has a potential impact on patient safety issues.

Culture of safety/ Culture of change

The definition of collaboration supports the culture of safety: Cooperative arrangement in which two or more parties (which may or may not have any previous relations) work jointly toward a common goal. The ESRD Core Survey process will analyze management behavior, safety systems, and patient/employee perception of safety. The surveyors will question both patients and employees about the facility’s support of open communication, consistent reporting of events/errors/near misses without fear of retribution, and evaluate if there are clear expectations for staff practices.

The traditional “blame/shame” culture does not protect patients because fear of retaliation hinders open communication and reporting of potential errors. The new “Culture of Safety” should include open, non-judgmental communication from top to bottom in the organization. The Governing Body and interdisciplinary team must give clear direction for all staff as to what is expected of them. Also, the facility must construct a robust system for reporting, investigating, and addressing abnormal events and near misses.

In December 2013, the Department of Health and Human Services Office of the Inspector General (OIG) released a report that studied over 5,000 dialysis facilities that provide life-sustaining treatments to Medicare beneficiaries. This report is available at The OIG learned that facilities must strengthen their process for handling grievances to avoid retaliation against patients and/or their families.

This change to a culture of safety will be the biggest challenge for organizations to deal with because it involves a culture shift: listening to staff and patients with an open mind that actually encourages them to report problems or near misses. Last year at a NRAA pre-conference workshop on the Core Survey Process, Nancy Bobola, RN, BS, MS presented several questions to the audience about listening to staff voices:

What is your role in patient safety?  How do you prevent errors (your own/others)?

What errors/near misses would you report?

Do you feel safe reporting errors/suggestions?

How are errors addressed?  What is your role in follow-up?

How are you involved in the QAPI program?  How are QAPI goals and action plans shared with you or other employees?

Listening to patient voices is a key component of the culture of safety.  Questions to patients to determine if they feel that the staff listens to their perspective include:

Do staff members encourage you to report problems or complaints?  To whom? Do you feel comfortable with reporting?  If not, why not?

Do staff members treat you with dignity and respect?

Do you see staff following infection control policies by washing their hands often?

Do you feel there is enough staff to take care of you during your treatment?

Do you feel you are receiving quality care?

These are great questions to start the conversations necessary in changing the culture within the organization. All staff members and patients should be able to answer these questions with confidence and enthusiasm. How does your organization measure up?

Next month in Part 2: Observations of care and how the QAPI team assures quality of care.