http://www.renalbusiness.com/articles/the-need-for-accountability-in-dialysis.html#Viewpoint: The Many Faces of Quality Care and a Need for Accountability
Copyright 2008 by Virgo Publishing.
http://www.renalbusiness.com/By: Roberta Mikles, RN, BA
Posted on: 06/30/2008
There has been concern regarding quality care and patient safety in dialysis facilities for many years. All patients expect quality safe care when entering any healthcare setting. Patients entering into the dialysis setting, where they will be receiving complicated life-sustaining dialysis treatments, have the same expectation and rely on providers to ensure quality care.
The Centers for Medicare & Medicaid Services (CMS) outlined in the ESRD Quality Improvement Initiative—Patient Safety that, “Giving the right care, to the right patient, at the right time...” is the basis for quality care. However, quality care reaches beyond clinical performance measures into more specific areas that are, often, only identified during the clinic survey process.”
Delivery of quality safe care is in the hands of the provider.
Continued Problems
Eight years ago, one of several Office of Inspector General, Health and Human Services reports made recommendations to the Health Care Financing Administration (now CMS) to “...hold individual dialysis facilities more fully accountable for the quality of care.”1 It also said the Medicare Conditions for Coverage should be revised “...for dialysis facilities so that they serve as a more effective foundation for accountability.”1
In a May 2000 letter to the Inspector General, the American Association of Kidney Patients agreed with recommendations that, (at the time HCFA), should hold “...state CMS survey agencies more fully accountable for their performance in overseeing the quality of care provided by dialysis facilities.” The letter went on to say that “...these recommendations could lead to better patient health outcomes and longevity.”
To date, CMS has been unable to successfully hold dialysis facilities more accountable due to an ineffective oversight and enforcement program. States, such as California—and there may be others—are unable to fulfill CMS’ request, resulting in an ineffective program. In addition, effective statutory sanctions that would provide incentive for compliance, are lacking.
We see continuing deficiencies in centers cited for practices that result in potential or actual negative outcomes, including death. Determining provider accountability and condition compliance will be difficult—even though CMS revised the Medicare Conditions for Coverage in 2008—due to the existing ineffective oversight and enforcement program. Even with CMS developing Clinical Performance Measures (CPM), one must remember there is more to quality care than CPMs. Quality care is dependent upon timely surveys to effect continued compliance and an effective sanctioning process.
Unquestionably, CMS and Congress need to reassess and explore other means of determining and ensuring ESRD compliance.
The GAO Report
Five years ago, the Government Accountability Office recommended the following: “GAO suggests that Congress consider authorizing CMS to impose immediate sanctions, such as monetary penalties or denying payment for new Medicare patients, on dialysis facilities cited with serious deficiencies in consecutive surveys. GAO recommends that the CMS Administrator create incentives for facilities to maintain compliance with quality standards, increase use of expert staff in conducting ESRD facility surveys, and enhance the support and monitoring of state survey agencies. CMS did not indicate an intention to implement five of our six recommendations.”2
The report added: “As a result of critical weaknesses in the system established to monitor and enforce compliance with Medicare’s quality standards for ESRD facilities, full and consistent compliance with these standards has become more the exception than the rule.”2
Enforcement was also of concern, and the GAO wrote, “...there are few if any negative consequences for facilities if they are surveyed and found out of compliance with Medicare’s quality standards.”2 Disclosure of deficiencies was also addressed and stated, “Currently, facilities can escape negative publicity from having multiple deficiencies, despite the fact that the statement of deficiencies prepared by the state surveyors is a public document.”2 Of even greater concern was that this report cited problems at facilities that created potential for harm to patients.2 This statement was the result of a review of recertification survey reports between 2001 and 2002, collected from 10 states.
To date, there are no statutory sanctions available for dialysis facilities similar to that of the nursing home scope and severity grid to determine sanction type. The lack of negative consequences, e.g., implementing similar to the nursing homes grid, continues to promote noncompliance. Many facilities that have serious noncompliance areas, that place patients in potential or actual harm, continue to go unnoticed by patients, taxpayers and other concerned individuals who support the dialysis industry. Many survey reports between 2003 and 2004, two years after this time frame noted in the report, cited deficiencies that resulted in potential or actual negative outcomes. More survey reports, from 2004 to 2006, four years after this report date, continued to cite deficiencies that resulted in potential or actual negative outcomes.
Of significant awareness is that a considerable number of these deficiencies might not have been known if it were not for the survey. Therefore, it is imperative that surveys are conducted in a timely manner to ensure ESRD compliance, resulting in quality safe care. Perhaps, investigation into an improved oversight and enforcement program would be beneficial for patients and ensure quality safe care for all.
Provider, would you want to be on the receiving end of a preventable potential or actual negative outcome, or preventable death?
The Responsibility of Elected Officials
For the well-being of patients, Congress must address needed statutory repair. If Congress can meet with providers, professional organizations and patients, and address areas such as funding for pre-dialysis education, kidney education and increased provider reimbursement, then why is Congress not looking at and addressing the fact that there are continuing problems in dialysis facilities, as evidenced by survey findings? Deficiencies cited during the survey process will not be resolved by the new clinical performance measures. These deficiencies usually are based in not adhering to practices and procedures that ensure quality safe care. Some deficiencies can support poor clinical performance measures.
Surveys have a voice of their own, and provider denial and related rhetoric is an insult to many, including those patients who have experienced a potential or actual negative outcome, as well as those families who have lost a loved one as a result of a preventable negative outcome.
Congress should further address inclusion of data from survey findings on Dialysis Facility Compare, similar to Nursing Home Compare. In fact, one expert in the dialysis field states, “Presently, due to aggressive lobbying from large corporations, quality reporting is skewed to make providers look better than they are. As a result, the mortality and quality data being reported at Dialysis Facility Compare is worthless to the consumer.”3 Therefore, is it not reasonable to include data from survey findings on Dialysis Facility Compare? This data clearly illustrates the type of care a facility provides, and supports patients being empowered to make informed and educated choices and decisions. Survey data, in addition to accurate information related to clinical performance measures, illustrates if a facility is providing quality safe care. This data will give consumers information related to those facilities that provide excellent care to those who provide substandard care.
Should those patients who have been on the receiving end of a negative outcome address our elected officials? Should those families who have lost a loved one, as a result of a preventable error, address our elected officials? Perhaps, just perhaps, our elected officials need to hear from this group of individuals.
In addressing Medicare funding, one must ask, What are the priorities? Many realize the importance of educational programs, paying providers for quality care and other areas; however, determination of quality safe care is foremost. Without a doubt, it is evident that the survey process is a valuable tool that can improve and save lives. In conjunction, there must be an effective statutory sanctioning process, as stated, similar to the nursing home scope and severity grid. Quality safe care is the priority. It seems that the bottom line is that CMS and Congress must explore other avenues to ensuring all patients are receiving quality safe care.
In conclusion, all are aware, although some are in denial, that for the last eight years or more, a significant number of survey findings have shown patients are being placed in situations of preventable potential or actual negative outcomes, including death. This is unacceptable. Providers, CMS, and our elected officials, in desire of all patients receiving quality safe care, should understand that one preventable death is one too many. The sobering awakening that many preventable mistakes cost patients, not only their quality of life, but their life, must be addressed. To ensure quality “safe” care, dialysis facilities entering into the Medicare program, should be subject to certain conditions, such as the following: (a) providers pay a minimal survey fee that will ensure and result in an annual facility inspection/survey to ascertain ESRD condition compliance, and (b) provider reimbursement will be contingent upon ESRD condition compliance. In addition, dialysis facilities should be held as accountable as hospitals, and withholding of Medicare reimbursement should be considered for certain preventable negative outcomes, including death, similar to that which is being implemented for hospitals.
Provide care as you would want care to be given to yourself or a loved one. RBT
Roberta Mikles, RN, BA, is a healthcare patient advocate based in San Diego. She can be reached at RMiklesRN@aol.com
References:
1.
http://oig.hhs.gov/oei/reports/oei-01-99-00050.PDF, Department of Health and Human Services, Office of Inspector General, External Quality Review of Dialysis Facilities, A Call for Greater Accountability. June 2000, June Gibbs Brown, Inspector General, OEI-01-00050
2. 2003 United States General Accounting Office, Report to the Chairman, Committee on Finance, U.S. Senate, October 2003, Dialysis Facilities: Problems Remain in Ensuring Compliance with Medicare Quality Standards. GAO-04-63
www.gao.gov/cgi-bin/getrpt?GAO-04-633. Statement - Joe Atkins, RN CNN MBA, CEO Medical Concepts & Innovations, Mr. Atkins has 36 years experience in the dialysis field, including 20 years in ESRD management. Mr. Atkins is a former dialysis facility owner.
What is Quality Care?
Entering into the healthcare business, especially delivering complicated dialysis treatments, carries with it an enormous responsibility that must ensure patients are receiving quality safe care. This life-sustaining treatment can become life-threatening, in a second’s time. Staff should be adequately educated and trained to meet individual patient needs before, during and after treatments, as well as listening to, acknowledging and resolving patient complaints. In addition, clinics should promote an atmosphere to prevent patients from feeling fear of reprisal for questioning practices or asking questions. Clinics should provide honest reasons when mistakes occur. ESRD conditions should be adhered to, ensuring compliance-facility policies and procedures, ensuring staff are following physician orders, and ensuring staff are compliant with standards of care. Staff should be educated to understand what the patient is experiencing, and patient education and active involvement in their treatment.
Real Clinic Benefits of Quality Care
With providers becoming even more responsible for ensuring their patients receive quality care, caregivers might observe the following in patient areas.
Decrease in preventable potential negative outcomes
Decrease in preventable actual negative outcomes, including, but not limited to, death
Decreased numbers of costly preventable hospitalizations that often result in additional acquired costly medical conditions and increased hospital length of stay
Decreased costly days spent in rehabilitation/nursing homes, post-acute care hospitalization, decreased costly home health visits, supplies, medical devices, durable equipment, etc.
Decrease in unnecessary medications
Improvement in patient outcomes
Improvement in patients’ quality of life, general well-being and longevity
Additionally, providers might observe the following.
Fewer complaints filed
Decrease in lawsuits filed
Decrease in malpractice insurance, and other insurance premiums
Patient satisfaction
Improved patient-provider relationships
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