Forum of the End-Stage Renal Disease Networks' Role in Implementing the National Kidney Foundation-Dialysis Outcomes Quality Initiative Clinical Practice Guidelines

The development and release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines marks an important step in the on-going process of improving the renal dialysis patient's outcomes. The Forum of End-Stage Renal Disease (ESRD) Networks' role in this process should be considered within the context of its mission and the ESRD Networks' Congressional mandate. In addition, facilitating the implementation of the NKF-DOQI Guidelines is one component of the Forum's current quality-related agenda. Environmental trends and current research indicate a variety of factors critical to the successful implementation of the NKF-DOQI Guidelines. The Forum's plan encompasses each of the following key elements: defining and evaluating the Guidelines and clinical performance measures (CPMs); prioritizing and locally disseminating NKF-DOQI Guidelines; converting NKF-DOQI Guidelines into CPMs; expanding the information infrastructure; and conducting quality activities and engaging local physicians. Keeping in mind the broader national agenda for quality improvement in the renal community, including continuing medical education programs focused on quality measurement and improvement tools and techniques, developing decision support tools and increasing on-line access to evidence-based reports and literature is important as well. Carrying out the Forum's plan for implementing the NKF-DOQI Guidelines, in collaboration with national nephrology professional and patient organizations, will facilitate Guideline adoption and use across the renal community.     

Measuring Osteoporosis Quality: The Work of the Joint Commission

Recognizing the significant impact of osteoporosis, The Joint Commission has worked since 2005 to develop performance measures in osteoporosis across the care continuum. This work has led to the development of 3 measures, which may be used at any time to meet hospital quality improvement goals. Plans are in place to submit to the National Quality Forum for endorsement as national consensus standards. The measures were developed under the guidance of a 12 member Technical Advisory Panel.     

Quality Measurement in Orthopaedics: The Purchasers’ View

While all of medicine is under pressure to increase transparency and accountability, joint replacement subspecialists will face special scrutiny. Disclosures of questionable consulting fees, a demographic shift to younger patients, and uncertainty about the marginal benefits of product innovation in a time of great cost pressure invite a serious and progressive response from the profession. Current efforts to standardize measures by the National Quality Forum and PQRI will not address the concerns of purchasers, payors, or policy makers. Instead, they will ask the profession to document its commitment to appropriateness, stewardship of resources, coordination of care, and patient-centeredness. One mechanism for addressing these expectations is voluntary development of a uniform national registry for joint replacements that includes capture of preoperative appropriateness indicators, device monitoring information, revision rates, and structured postoperative patient followup. A national registry should support performance feedback and quality improvement activity, but it must also be designed to satisfy payor, purchaser, policymaker, and patient needs for information. Professional societies in orthopaedics should lead a collaborative process to develop metrics, infrastructure, and reporting formats that support continuous improvement and public accountability.     

Doing More Than Caring About Quality

The treatment of chronically ill patients with end stage renal disease (ESRD) receiving dialysis therapies has advanced greatly over the years and accomplished many successes in prolonging the life of patients with ESRD, yet has had considerable failures due to the inability to compensate for all functions of the kidneys. In addition, the focus to achieve quality goals for laboratories and vascular access measures may indicate a good quality of care from providers, but meeting these clinical and physiological goals may not fully maximize individual benefit to a patient, may not be aligned with the patient's care goals, and could conceivably impact negatively the patient's experience of care and quality of life. The age of individualized patient centered care is forthcoming with advancements in technology and our understanding of the treatment of renal diseases. The future holds promise for enhancing the quality provided to each patient but will require nephrologists to overcome numerous hurdles. This article provides an opinion on principles that may fundamentally improve the quality of renal disease care in the future and represents themes that can enhance quality, safety, and efficiency in the health care delivery system. It is believed that quality measured from a patient centric perspective will shift the treatment for these chronic disorders to better meet each patient's needs and goals, while evolving an enhanced delivery system for the care of all ESRD patients.     

Quality and accountability in the ESRD program

The quality of care received by patients with end-stage renal disease (ESRD) in the United States has received considerable public attention during the past several years because of a number of social, economic, and political factors. There has been a lingering impression that the poorer survival of dialysis patients in the United States, compared with their counterparts in other industrialized countries, is because of process factors for which there are opportunities for improvement, rather than just an adverse case mix. Recent reports by the Office of the Inspector General and the General Accounting Office have recommended that the Health Care Financing Administration (HCFA) improve its oversight of dialysis providers and hold the providers more accountable for their patient care outcomes. This requires the development of validated clinical performance measures that, in turn, should be derived from evidence-based clinical practice guidelines. The dual oversight model, with the state survey agencies agencies performing a quality assurance function to require facilities to meet minimal standards of operation (Medicare's conditions of participation) to prevent patient harm, and with the ESRD Networks performing a quality improvement function to bring processes and outcomes for all patients to a higher level, appears to be sound. HCFA's move toward increased provider accountability has included the development of facility-specific profiles for processes of care (dialysis adequacy) and outcomes (hemoglobin level and standardized mortality ratio), which may trigger state surveyor activities and that will be available for public scrutiny on a HCFA-sponsored web site. The adoption and application of continuous quality improvement methodologies at the dialysis provider level will be an important strategy for favorably positioning the facility in a competitive and demanding health care marketplace.     

Local implementation of clinical practice guidelines and continuous quality improvement: challenges and opportunities

Implementing clinical practice guidelines (CPGs), disease management programs, and quality improvement projects requires an understanding of the trends that will facilitate adoption at the local level. These trends include consumerism and the building of a national information technology infrastructure. The recommendations of the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry and the Institute of Medicine (IOM) report entitled “To Err Is Human: Building a Safer Health System” will frame developments and implementation. The relative roles and responsibilities of national entities, with coordination and integration of these activities with local efforts will need to be carefully orchestrated. Utilizing the Web to connect dialysis facilities, patients, and members of the health care delivery team has the potential to reap large benefits. Utilizing information technology at the point of care and retrospectively to improve decision making by all parties has the real potential to improve patient outcomes. Implementation of what at a local level? And what do we mean when local level is referred to? This article addresses these two questions and provides a framework for the engagement of patients, physicians, and members of the health care delivery team and organizations, at both the local and national levels, in improving patient outcomes. All have their roles, rights, and responsibilities. We are challenged to provide the right treatment, to the right patient, at the right time. And importantly, to provide the right information, to the right person, at the right time.     

In Quality We Trust; but Quality of Life or Quality of Care?

The ESRD program provides medical care to a diverse and medically complex patient population. The care for the ESRD patient population has become increasingly benchmarked with process of care measures. These measures include dialysis adequacy, anemia, nutrition, and vascular access outcomes. These process‐related dialysis measures may not improve the care of the individual patient as care relates to the individual's goals and values. There is also evidence that these process measures may not be causally related to quality of life, hospitalization, and survival. The adoption of patient‐reported outcomes may shift the balance toward more patient‐centered care. However, the extent to which mandated measures of health‐related quality of life and patient satisfaction result in improved outcomes remains unclear.     

Clinical practice guidelines in end-stage renal disease: a strategy for implementation

Clinical practice guidelines (CPGs) for end-stage renal failure (ESRD) were recently published, and represent a comprehensive review of available literature and the considered judgment of experts in ESRD. To prioritize and implement these guidelines, the evidence underlying each guideline should be ranked and the attributes of each should be defined. Strategies to improve practice patterns should be tested. Focused information for each high priority guideline should be disseminated, including a synopsis and assessment of the underlying evidence, the evidence model used to develop that guideline, and suggested strategies for CPG implementation. Clinical performance measures should be developed and used to measure current practice, and the success of changing practice patterns on clinical outcomes. Individual practitioners and dialysis facilities should be encouraged to utilize continuous quality improvement techniques to put the guidelines into effect. Local implementation should proceed at the same time as a national project to convert high priority CPGs into clinical performance measures proceeds. Patients and patient care organizations should participate in this process, and professional organizations must make a strong commitment to educate clinicians in the methodology of CPG and performance measure development and the techniques of continuous quality improvement. Health care regulators should understand that CPGs are not standards, but are statements that assist practitioners and patients in making decisions.     

Goal setting & Network 9/10 efforts to improve care

TRN, through its Medical Review Board, has developed, endorsed, and articulated goals for two aspects of dialysis treatment. These goals promote the use of continuous quality improvement by encouraging dialysis programs to perform internal examinations of their own data in the context of regional and national data. TRN believes that this combination of data feedback, CQI, and goal setting will impact positively on patient outcomes for all dialysis patients within The Renal Network.     

American osteopathic association commitment to quality and lifelong learning

The American Osteopathic Association (AOA) initiated programs to enhance quality for 54,000 doctors of osteopathic medicine (DOs) practicing in the United States. Seven core competencies are required in undergraduate and graduate medical education standards. They include osteopathic philosophy and osteopathic manipulative medicine, medical knowledge, patient care, professionalism, interpersonal or communication skills, practice-based learning, and systems-based practice. The AOA Clinical Assessment Program (AOA-CAP) is a quality-improvement tool for physicians to evaluate the safety of patient care. Osteopathic residents and practicing physicians measure the quality and safety of patient care using evidence-based standards through an AOA-supported, Web-based architecture. Alternative models for recertification, including a Maintenance of Certification (MOC) process, are under review by the AOA, the Bureau of Osteopathic Specialists (BOS), and osteopathic certifying boards. The BOS establishes and maintains standards for the various osteopathic certifying boards and oversees matters of policy, jurisdiction, and standards review. The American Osteopathic Board of Emergency Medicine is the first osteopathic board to adopt a MOC process. The goals of the AOA's continuing medical education (CME) program are continued excellence of patient care and improvement of health and well-being of individual patients and the public. The AOA agrees that CME will play a critical role in recertification and continual assessment of physician competence. The AOA believes that proposed activities of the Conjoint Committee on CME and quality initiatives of the osteopathic profession are in tandem with goals and quality initiatives of the AOA.     

Functional Assessment in End‐Stage Renal Disease: Enhancing Quality of Life

Why do functional assessments in patients with end‐stage renal disease (ESRD) matter? Multiple studies show that new dialysis patients undergo a substantial decline among activities of daily living. Moreover, poor functional status in ESRD patients is associated with early morality. That is why CMS has developed new criteria to assess ESRD patients in regards to their functional, psychologic, and cognitive capabilities. Functional assessments by health providers have been used in field of Rehabilitation Medicine for over 50 years; rehabilitation physicians have found them effective in establishing goals and monitoring improvement. Assessments can provide guidance by identifying the needs and types of intervention most suited for patients. Impairments can be addressed with referrals to physical therapy for gross motor issues, occupational therapy for self‐care problems, psychiatry for mental disorders, and neurology for cognitive deficits. The more accurate the assessments over time, the more targeted and effective the therapies become. We believe that the new CMS goals to assess functionality will improve ESRD patient's quality of life, longevity, and long‐term healthcare costs.     

Metabolic syndrome and chronic kidney disease: a Japanese perspective on a worldwide problem

Metabolic syndrome and obesity have causative roles in the development of chronic kidney disease (CKD). CKD leads to end-stage renal disease (ESRD), cardiovascular disease and death. The prevalence of metabolic syndrome is increasing worldwide in both developing and developed countries. Early detection and treatment of metabolic syndrome would be a cost-effective strategy to target the increasing prevalence of ESRD. Therefore, subjects with metabolic syndrome are candidates for CKD screening via dipstick proteinuria testing and serum creatinine measurements. The international community is beginning to share information on CKD through World Kidney Day, Kidney Disease Improving Global Outcomes, Commission for the Global Advancement of Nephrology, International Society of Nephrology and other scientific societies. The Japanese Society of Nephrology initiated the Asian Forum of CKD Initiative 2007 to discuss regional issues related to CKD in Asian countries. The clinical effects of metabolic syndrome vary among ethnic groups. A fundamental scientific question is the ethnic factor for calculating the glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease Study equation. The incidence and prevalence of CKD are closely related with lifestyle factors such as diet, exercise, tobacco use, as well as other cultural differences. Research on the relationship between CKD and metabolic syndrome may provide clues to better understand the role of lifestyle-related factors and the age-related decline in GFR.     

Hemodialysis Adequacy and the Hospitalized End‐Stage Renal Disease Patient—Raising Awareness

Assessment of hemodialysis adequacy may require different approaches for the stable, outpatient with end‐stage renal disease (ESRD) and for the sick, inpatient with acute kidney injury (AKI). Variability of urea distribution volume, urea generation, and treatment schedule, for instance, complicates dialysis dosing in the latter group although progress has been made in our understanding of their needs. There is a third population, however, for whom hemodialysis dosing requirements remain unclear—the hospitalized ESRD patient. This commentary discusses the key urea kinetic differences between stable ESRD and AKI to give the context to where, on the intervening spectrum, the hospitalized ESRD patient might lie. The limited literature examining hemodialysis dosing in this population is discussed along with those outstanding questions that might form the basis of a future research agenda.     

The value of developing a quality assurance program--Part III

It is fundamental that quality, incorporated as a service, be provided. Assessing employees' input through a survey is an essential process. By developing, implementing and responding to staff questionnaires, a facility shows commitment to quality improvement. The mission and philosophy of a facility needs to incorporate employees concerns, and utilize this information towards the goal of improved patient care.     

Prioritizing Patient‐Reported Outcomes in Breast Cancer Surgery Quality Improvement

Breast‐cancer‐specific tools that measure health‐related quality of life (HRQOL) were developed for use in research or clinical practice, and little is known about these tools’ performance ability for quality improvement. Furthermore, existing tools may not fully reflect all issues that contribute to quality care as seen by patients. Work is needed to identify and validate patient‐reported outcome measures for use in quality improvement in breast cancer surgical care. We conducted an exploratory qualitative study in order to better understand what HRQOL domains and processes of care define high quality surgical care for women undergoing mastectomy for breast cancer from both the patient and clinician perspective. We conducted focus groups and one‐on‐one interviews with 15 women and administered a prioritization questionnaire to participants. We also conducted a prioritization questionnaire among surgical oncologists, general surgeons, and reconstructive surgeons who are members of the Washington State Medical Association. Both the patient and surgeon prioritization questionnaire asked participants to prioritize HRQOL and treatment satisfaction‐related aspects of their breast cancer surgical care at key time points before and after mastectomy. A Stakeholder Advisory Panel was convened to review focus group, interview, and prioritization questionnaire results and make recommendations as to patient‐reported outcome domains to focus on and existing instruments to use for quality improvement. Patients and clinicians largely agreed on important HRQOL domains, including emotional well‐being, education, communication, and process of care. The Stakeholder Advisory Panel, composed of 12 clinicians and five patients, reviewed study findings and existing patient‐reported outcomes measurement tools. The panel recommended that the BREAST‐Q, a flexible tool with independently validated modules designed for research and clinical care, is an ideal tool to begin developing novel quality improvement benchmarks focused on patient‐reported outcomes.     

Resultado de la implementación de un sistema de gestión de la calidad en base a la Norma ISO 9001:2015 en una unidad de cuidados intensivos quirúrgica

IntroductionThe implementation of Quality Management Systems (QMS) is one of the fundamental and future-oriented elements for the improvement of modern health systems. The objective of implementing a QMS in accordance with the requirements of the ISO 9001:2015 Standard is to effectively carry out its activities, covering both technical and management aspects, guaranteeing the satisfaction of the needs and expectations of all its stakeholders, as well as compliance with legal and regulatory requirements. It must contemplate all those aspects that have an impact on the final quality of the product or service provided by the organization.ObjectiveThe main objective is to describe the process of implementing a QMS under the ISO 9001:2015 Standard in the Surgical Intensive Care Unit of the General University Hospital of Elche and evaluate its results.MethodologyCarrying out and implementing a QMS in the Surgical Intensive Care Unit of the General University Hospital of Elche applying the points of the ISO 9001:2015 Standard. The SGC has followed the benchmark of management by processes, identifying from its strategic core of mission, vision and values, the different processes involved and their interrelation reflected in the process map. Based on it, the necessary documents have been developed to describe the operation of the Unit both at an operational level through the key processes (admission and initial assessment of the patient, stabilization, follow-up, complementary tests, interconsultations, transfers and discharge) as well as which refers to procedures of a strategic or support type.ResultsThe strategic lines that marked the beginning of the deployment of our QMS were defined with the drafting of 7 objectives, achieving 100% compliance. The key processes (7) that described the functioning of our organization were elaborated, as well as those of a strategic type (14) and support or support (5), complemented with 55 medical and nursing protocols. Twenty monitoring indicators were analyzed: 6 organizational and planning type, and 14 clinical. Forty-six incidents were detected in the first year of implementation of the QMS that were analyzed by the Quality Commission, emerging 7 corrective actions. Fourteen improvement actions were developed after the application of the AMFE methodology for key processes, achieving an average of greater than 70% effectiveness after reassessment. From the analysis of patient and family satisfaction through SAIP case management, 41 of a total of 52 cases were acknowledgments in writing.ConclusionsImplementing a QMS in our Surgical Intensive Care Unit has made it possible to define the strategic lines of our organization, develop objectives, establish monitoring indicators, standardize the work of the Unit through procedures and protocols, increase safety at work through the use of lists of verification, initiate improvement actions to strengthen the weak points of the QMS itself, as well as know the degree of satisfaction and needs of our patients and the personnel who work in it.     

Promoting quality of care for ESRD patients: the role of the ESRD Networks

The 18 End Stage Renal Disease (ESRD) Networks were established by Congress to oversee the care of Medicare beneficiaries with ESRD, serving as HCFA's primary quality improvement (QI) agents. The Networks play a critical role in the ESRD surveillance system by collecting, analyzing and disseminating data from dialysis clinics regarding the occurrence of ESRD, and the processes of care and outcomes of ESRD patients. In addition, under the direction of volunteer Medical Review Boards, the Networks propose, design and implement regional QI activities targeting specific areas in the delivery of ESRD care, and provide technical assistance to foster QI at the facility level. In this article, we discuss the ESRD Network system and review the scope of QI activities through which the Networks accomplish their mission.     

Bariatric Surgery Postoperative Behavioral Change: The Importance of Ongoing Assessment and Teaching

In bariatric surgery we modify, in varying degrees, the gastrointestinal system. We observe the patients clinically over the postoperative period of a few months or more. During this time our main concern is to monitor them physiologically, noting the decline in weight, change in body structure, and vast improvement in their comorbidities. Frequently the reaction of the patient may be somewhat surprising to us. One or 2 years past surgery they have forgotten about having had diabetes and hypertension, diseases for which they had received a barrage of medical treatment. It does not seem to matter anymore that at one time they wore a size 2X and now can wear size 14. Now we are forced to wonder what the expectation of the patient was. Our goal was to improve their physiological and psychological wellbeing, assuming they would go hand in hand with weight loss. If the patient does not recognize an improvement in their quality of life and continues to question their selfworth, then perhaps we should reassess our goals and our obligations. The principles of surgery and how it is or should be done is fairly clear. If we are to maintain standards of quality in this particular field of medicine, we must recognize our commitment to patients and make these principles just as clear. The commitment involves ongoing postoperative assessment and teaching, assessment of emotional well-being and lessons in dietary and physical activity, including exposure to and involvement in group support.     

PD First: Peritoneal Dialysis as the Default Transition to Dialysis Therapy

Peritoneal dialysis (PD) and in‐center hemodialysis (HD) are accepted as clinically equivalent dialysis modalities, yet in‐center HD is the predominant renal replacement therapy (RRT) modality offered to new end‐stage renal disease (ESRD) patients in the United States and most other industrialized nations. This predominance has little to do with clinical outcomes, patient choice, cost, or quality of life. It has been driven by ease of HD initiation, physician experience and training, inadequate pre‐ESRD patient education, ample in‐center HD capacity, and lack of adequate infrastructure for PD‐related care. As compared with in‐center HD, PD is a widely applicable, yet underutilized modality of RRT that provides comparable clinical outcomes, superior quality of life measures, significant cost savings, and many other unmeasured advantages. A “PD First” approach not only has advantages for patients but also physicians, healthcare systems, and society. In this review, we will summarize evidence demonstrating that PD should be the default modality when new ESRD patients are transitioning to dialysis therapy when preemptive transplantation is not an option and highlight the essential infrastructural requirements to allow for a “PD First” model.     

Exercise in End‐Stage Renal Disease

This article will outline the clinical reasoning for exercise counseling in end‐stage renal disease (ESRD) patients and give healthcare providers detailed information on the different programs that can be implemented in this population according to patients’ specific needs. End‐stage renal disease patients often have other health problems that can be improved by participation in regular exercise programs. Research accumulated during the last 30 years on exercise for the ESRD population supports its numerous beneficial effects including those on cardiovascular capacity, sarcopenia, and health‐related quality of life. We describe the different types of exercise, aerobic and resistance programs (including their frequency, intensity and progression) that are recommended for the ESRD population, as well as the potential goals of each program. Groups with special needs among the ESRD population are considered, as well as safety, potential adverse events, and adherence to exercise programs. Finally, recommendations for future researches are highlighted.