The Nephrologist as Team Leader

Within the last 2 years dialysis facilities in the US have been adjusting to the now not-so-new Center for Medicare & Medicaid Services (CMS) Conditions of Coverage. CMS, as many of you know, funds the ESRD program to the tune of many billions of dollars and as such gets to set some of the rules, known as "Conditions of Coverage". These rules are designed to ensure quality of service from their perspective. Auditors acting on behalf of CMS periodically survey dialysis facilities in a rigorous fashion and may (and often do) issue citations and conditional warnings as result.
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".
It went on to append a summary of findings from recent audits, occurring in a particular geographical region, identifying some of the deficiencies which have been noted by the auditors as citable or worthy of a conditional warning. Here are a few of them:


Infection control standards not met due to: 

- Patients not washing and sanitizing their hands pre and post treatment 

- Staff members accessing computer terminals with gloves on after patient contact 

- Patients self holding needle access sites post treatment without gloves on 



Physical environment standards not met due to: 

- Unsanitary and non working sinks and faucets 

- Open boxes of needles and syringes not properly stored 



Documentation requirements not met due to: 

- Incomplete Interdisciplinary Team assessments 

- Medical records not stored properly 

- Peritoneal dialysis orders incompletely and improperly written. 



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. But, the ability to develop and lead a team in the delivery of care to a defined patient population such as an office practice or a dialysis facility may be as important as an extensive clinical knowledge base in terms of improving outcomes. Being able to function as a clinician and a team leader is a challenge and interestingly many of the leadership skills we eventually acquired are done so by osmosis and without direct teaching.

For those interested the Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule can be found in the Federal Register / Vol. 73, No. 73 / Tuesday, April 15, 2008 / Rules and Regulations. It is ~ 120 pages but is worth reviewing if you are planning career involving outpatient dialysis care.


Posted by David Steele M.D.