Quality and accountability in the ESRD program

The quality of care received by patients with end-stage renal disease (ESRD ) in the United States has received considerable public attention during th e past several years because of a number of social, economic, and political factors. There has been a lingering impression that the poorer survival of dialysis patients in the United States, compared with their counterparts i n other industrialized countries, is because of process factors for which t here are opportunities for improvement, rather than just an adverse case mi x. Recent reports by the Office of the Inspector General and the General Ac counting Office have recommended that the Health Care Financing Administrat ion (HCFA) improve its oversight of dialysis providers and hold the provide rs more accountable for their patient care outcomes. This requires the deve lopment of validated clinical performance measures that, in turn, should be derived from evidence-based clinical practice guidelines. The dual oversig ht model, with the state survey agencies agencies performing a quality assu rance function to require facilities to m eet minim al standards of operati on (Medica re's conditions of participation) to prevent patient harm, and w ith the ESRD Networks performing a quality improvement function to bring pr ocesses and outcomes for all patients to a higher level, appears to be soun d. HCFA's move toward increased provider accountability has included the de velopment of facility-specific profiles for processes of care (dialysis ade quacy) and outcomes (hemoglobin level and standardized mortality ratio), wh ich may trigger state surveyor activities and that will be available for pu blic scrutiny on a HCFA-sponsored web site. The adoption and application of continuous quality improvement methodologies at the dialysis provider leve l will be an important strategy for favorably positioning the facility in a competitive and demanding health care marketplace. (C) 2001 by the Nationa l Kidney Foundation, Inc.