Viewpoint: The Many Faces of Quality Care and a Need for Accountability

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.