Chapter 24 Management of quality in dialysis care

Like all healthcare, dialysis programs are undergoing a revolution in accountability. The government, accrediting and regulatory agencies, payers, and patients are holding healthcare organizations accountable for the delivery of high-quality, low-cost healthcare. Healthcare providers are being asked to explain the rationale behind their decisions and plans of care. Increased competition in the managed care environment also demands that providers be responsive to quality and cost issues. Continuous quality improvement (CQI) is a method used to address those concerns. CQI must be supported by a leadership style of total quality management (TQM), in which all members of the organization are motivated to go beyond meeting minimum standards by complying with regulatory requirements as they continually evaluate their performance with the goal of improving care and outcomes.

What is the medicare improvements for patients and providers act?

The Medicare Improvements for Patients and Providers Act (MIPPA) is legislation that was approved and passed by Congress in July 2008. This act has significant implications for the nephrology community. The core of the act is the development of a case-mix adjusted bundled payment rate, a pay for performance quality incentive, and an educational condition to help patients with chronic kidney disease (CKD) manage their disease process. This is the only modification in the payment rate since the composite rate was introduced in 1983.

The composite rate is a fixed rate that Medicare pays for each dialysis treatment. This fixed or composite rate covers all services rendered, including supplies, equipment, and medications associated with the dialysis treatment. Since the composite rate was established, many new treatment-related pharmaceuticals have become part of the standard dialysis treatment. These additional drugs, such as erythropoiesis-stimulating agents, vitamin D, and iron, were not included in the original composite rate and have been billed for separately, over and above the composite rate. Additionally, many new laboratory studies and supplies did not exist when the composite rate went into effect, so these too have been billed separately. With the increase in Medicare use for end-stage renal disease (ESRD) services, MIPPA has charged the Centers for Medicare & Medicaid Services (CMS) to develop a new bundled payment that will include the additional drugs and laboratory services. This new rule will also align dialysis facility payments based on quality performance measures. The new payment system is being phased in over a period of three years, beginning in January 2011.

What is continuous quality improvement?

CQI is the ongoing process of identifying opportunities to improve quality. It involves collecting data on the current situation, identifying ways to improve performance, introducing new and better approaches and methods to achieve desired outcomes, and then evaluating the interventions. When CQI is operating as intended, important aspects of care in need of improvement are identified before problems occur. All personnel contribute to CQI by being vigilant in recognizing care practices in need of improvement. A patient-centered perspective and questioning (e.g., “What about my work interferes with my ability to do what needs to be done to have the best possible outcome for patients?”) are effective ways to identify practices in need of improvement. The goal of CQI is to use data to make objective decisions without assigning blame or finding fault.

What is the origin of continuous quality improvement?

Quality management efforts began in manufacturing, where the focus was on product inspection. Quality management experts, such as W. Edwards Deming, recognized that it was not enough simply to evaluate the end product. He introduced the principles of CQI to improve and manage the production processes used to achieve a quality product.

What is quality assessment and performance improvement?

Quality Assessment and Performance Improvement (QAPI) is the name given by CMS to an internal program that ESRD facilities must develop to promote continuous improvement and outcomes (Box 24-1).

Box 24-1 V626 QAPI Condition Statement

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. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.

From The Centers for Medicare & Medicaid Services (CMS) Interpretive Guidance, April 2008.

Quality of care issues to address include, but are not limited to, dialysis adequacy, dialyzer reuse program, nutritional status, anemia management, vascular access, bone disease management, infection control, medical injuries and errors, patient education, patient survival, vaccinations, and physical and mental functioning. Facilities are expected to prioritize those areas affecting patient safety. The Measures Assessment Tool is a reference list of acceptable standards and values for clinical and quality outcomes (Table 24-1). CMS requires that all facilities have a written plan describing their QAPI program. Facilities are also required to constantly monitor their performance and to make performance improvements as needed using quality indicators or performance measures. Action plans must be prioritized and action that results in performance improvement must be taken.

Table 24-1 MEASURES ASSESSMENT TOOL

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