In the Dialysis Unit, Who is in Charge?

March 22, 2010
In the Dialysis Unit, Who is in Charge?

By Peter Laird, MD

Renal Fellow Network (RFN) is a great source of up to date information on renal issues at the level of a renal fellow. In such, I have learned much since the late Nathan Hellman, MD started his blog. However, there have been a couple of occasions where I believe that RFN needed to go deeper, especially on home dialysis issues.

The Renal Fellow Network is now a joint venture with the fellows and attending physicians at Mass General Hospital which is considered one of the leaders of quality medical care in America. In a recent post on the RFN, The Nephrologist as Team Leader, Dr. David Steele spoke about the new leadership role that a nephrologist is required to perform by the new CMS conditions of coverage:

In order to prepare for the eventuality of one of these surveys, I received a memo this week with a reminder of my responsibilities as the Hemodialysis Unit Medical Director:

"By virtue of the Medical Director's leadership of the facility's Governing Body, his/her responsibilities extend beyond the primary focus on improving quality of care delivered in the facility and extends to the general management and operations of the facility. As such, all condition level citations are linked to /and are the responsibility of the Medical Director according to CMS".

Dr Steele goes on to explain some of the newly mandated regulatory requirements, but in doing so, he freely points to the fact that the mentality of nephrology practice is that the dialysis unit runs itself with its nurses, techs and administrators.

What does this all mean? At first glance these citations/conditions may seem to be out of the realm of the practicing clinician whose focus is elsewhere, but in actuality they are integral to the proper care of our patients and the infection control lapses certainly should raise a high level of concern. We all have a natural disinclination to being surveyed but maybe these surveys are useful if they encourage us to put into place processes which ensure these lapses do not occur and if we develop systems of self assessment and quality improvement within our domain of responsibility.

Which brings me to the point of this blog. It's all about the team, and as Physicians we assume a natural leadership role when we deliver care to our patients and some of us are eventually appointed to leadership positions as our career advances. The usual dialysis unit personnel resources include Nurses, Patient Care Technologists, Dieticians, Social Workers and Administrative Staff. CMS is telling us we are responsible for the performance of this team on multiple levels. Traditionally our training has not focused much attention on preparing us for such leadership. (Emphasis Added)

When I was a practicing physician in the Army, we had many extra duties serving as medical director of different services in our hospital. In such, it was an excellent arena to develop leadership skills which were not only a requirement of being a physician in the hospital but it was also a requirement of an officer in the Army as well. The titles that I held clearly indicated who had the final authority and responsibility for that department: "Medical Director."

Yet somehow, the role of final authority as medical director of dialysis units has escaped this profession in many ways. This engenders several questions that need answers: Do American nephrologists traditionally focus on running a dialysis unit as a part of their nephrology training? Do American nephrologists get directed training as a team leader? According to this post on Renal Fellow Network, it appears that the answer is that this is a new role brought upon nephrology by CMS regulations. If CMS must tell the nephrologist to take charge, then who has been running the show up until now?

http://www.billpeckham.com/from_the_sharp_end_of_the/2010/03/who-is-in-charge-1.html