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?

Comments

[Ray]

What does this mean, are there going to b new rules and new changes in tthe way dialysis units are run? Why pay he director if it is run by niurses and techs and admin staff.

[Peter Laird, MD]

Nephrology is a highly trained specialty with many differing tasks. It is a central consulting specialty especially in the hospital with many of those in the ICU suffering from both acute and chronic renal conditions. Many nephrologists have minimized the impact on their schedule by only minimal oversight of dialysis units. Training for nephrology has also tended to lessen their emphasis on those patients already in the dialysis unit over those that they are trying to prevent ending up there.

I found the comments revealing that the oversight of the dialysis unit is considered a new duty which leads to the question of who has been in charge all of these years? I do not in the least envy the usual schedule of a nephrologist, nor do I envy the responsibility of their complex interventions many of which have potent toxicities, but I do find it surprising that they consider the mandated oversight a new leadership requirement. If you own and oversee a dialysis unit and prescribe all of the therapy in that unit, then the leadership role naturally follows in my opinion, not because of a new government mandate.

[Bill Peckham]

There are units, as you describe Peter - a nephrologist owns, is the medical director and follows all the patients but that is not the majority.

There are a lot of ways to structure the ownership of a dialysis unit - even units that are ostensibly part of a large chain can in fact be joint ventures - that said typically many units have multiple nephrologists who are the patient's MCPs, while the Medical Director may or may not follow patients.

Taking on the paid role of Medical Director use to have few specific charges under the Conditions of Participation (Conditions for Coverage) under the new ones they are responsible for the implementation of Policies and Procedures in keeping with the new Conditions of Participation. No one is forced to be a Medical Director - it's a job.

[somerville]

Among the 'dialysis unit personnel' should also be included the renal patients themselves, since active consultation with them is essential to avoid many needless errors. For example, I always had a dramatic hemoglobin decline whenever the EPO does was held, and one day a new nephrologist strolled by, believed my red blood cell count was too high, and slashed the dose for three weeks without telling me. To say that I needed a blood transfusion as a result of that idiocy would be an understatement. This all could have been avoided had he just informed me of what stupidity he was about to inflict.

It is ironic to speak of the nephrologist as having a 'leadership' role at the dialysis unit, when often only the renal nurses really know what is going on with the patient, or seem to care. There is a widespread philosophy of resignation among nephrologists, and the chief goal of therapy on their rare visits to the dialysis unit is to return home as soon as possible. The fact that nephrologist-run dialysis units have a much lower referral rate of patients for transplant -- since this is against the economic interest of the nephrologist-owners -- suggests that nephrologists are so profoundly unethical that the real leadership role in dialysis units should be assigned to the police.

[Robyn B.]

The Medical Director as leader of the dialysis facility is not a new CMS requirement. Although, in my experience, traditionally, the Medical Director had minimal personal involvement with the facility, CMS regulations has long deemed the Medical Director as the final responsible party . Normally, the "Nurse in Charge of Clinical Care" has been "running the show" and attempts to lessen the burden on the Medical Director to the point that the Medical Director often, only shows up to attend Governing Body and Quality Assurance meetings. As long as the Nurse is competent and capable, this model works very well when the facility is surveyed. It is when the Nursing leadership is lacking and the facility has severe deficiencies such as CFC (Conditions for Coverage) deficiencies, when surveyed, that the finger is pointed directly at the Medical Director. Unfortunately, often the Medical Director does not realize the responsibilities of the position and is caught by surprise when a facility receives a negative survey and the survey report casts the Medical Director in a very negative light by describing each Medical Director CMS regulation that is not being met. I am not, in any way, saying that the Medical Director should not be held accountable. Of course, one should always read the fine print and know what you are getting in to. I'm just saying that this is what I have seen and been involved in for many years. There are some Medical Directors that are very well informed and take their responsibilities very seriously but unfortunately, this is not the norm. I believe because there has been such a decline in the overall quality of care in dialysis facilities, that CMS has taken the gloves off and has become very focused/vocal in letting Medical Directors know that they are, ultimately, responsible for the quality of care/functionality of the dialysis unit.

[Anna Bennett Meinuk@aol.com]

When I was in-center at DaVita Lifecare in NYC, the Nephrologist would write the orders for lab work, the business office would review them, then place them if it were considered financially viable. My PTH was not checked as often as it should have been, because Davita only gets reimbursed for certain tests at certain times, and they did not want to lose money. I was over prescribed EPO and not prescribed Iron, so DaVtia benefited as an LDO for administering EPO, and I suffered by having my already depleted Iron stores wiped out.

DaVita Life Care in NYC is a GREAT real world case of "Who was in Charge?". Was it Dr. Wasser, the titular Medical Director who was fined $300,000.00 and had his license to operate taken away? Or was it DaVita, his Corporate Overlords who provided budgeting, staffing, staff incentives, policies and procedures, corporate branding, training and their McDonald's like business model of patient care? (hint - McDonald's isn't good for you either)

Nephrologists are people too, when DaVita woos an independent unit with a "Partnership" agreement (in NY State there were laws against corporate ownership - so found a loophole, a partnership/management agreement) it brings with it a built in infrastructure and centralized big box style for-profit dialysis. Who would say no to all the admin being done for them with the checks coming in the mail? It makes perfect business sense, and deadly medical practices. Nephrologist owned and operated dialysis units are being bought out and and signing a deal with the devil. As Dr. Wasser has learned. He is not innocent in the scandal that happened at DaVita Lifecare - but would it have been as bad if DaVita hadn't been running the show?

[Peter Laird, MD]

Dear Somerville, for once in a very long time, I am in absolute agreement with everything that you have said on this issue. Thank you for a breath of fresh air.

As a physician who trained not only at a well respected eastern medical school, but having experience in the military system, I have always assumed that every aspect of my patient's care was my entire responsibility. I went further to assume that I was also their final advocate and arbiter if I saw medical technicians or nurses who did not uphold the care that I expected for that patient. Perhaps that is why I was rated such a difficult patient when I went to incenter dialysis and as board certified internist did not relinquish that leadership role when I saw issues within the unit and I spoke up about them in an effective manner that got noticed. It is interesting to me to learn that nephrologists consider being the leader in the dialysis a new role.

A leading dialysis advocate schooled me on dialysis advocacy issues back in 2008 as I began to be involved with Bill's site and one of the biggest issues that they taught me about was how nephrologists do not pay enough attention to dialysis issues in many of their training programs and instead rely upon the nurses to run the unit as Robin so eloquently points out as well. This is not a new issue at all, but as a physician who spent his entire career assuming the leadership role with each of my patients, it is surprising to me to see that leadership role by the nephrologist in the dialysis unit is considered a new role.

The role of physician leader, physician advocate and physician director is a longstanding part of our profession that was drilled into my habits a long time ago both in medical school and in my residency. It is by the nature of the position a place where the buck does stop here, or at least that was my understanding during my years of practice.

[Peter Laird, MD]

Dear Anna, the tragic example of what happened to your unit and your nephrologist is indeed a wake up call to all nephrologists of how important their role is in a medical-legal sense. Tragically, I believe the reports that I read is that Dr. Wasser lost his right to practice. This is unfortunately an example of how nephrologists have in a sense abdicated their traditional role as the leader of the complete care of the patient. Europe utilizes fully trained nurses where here in America the majority of the work is done by the technicians which further compounds patient care in dialysis units. Having discussed dialysis issues with techs for over two years, their fund of knowledge of medical issues is quite rudimentary.

These issues make the active supervision by the physician even more important here in America. Preventing transmissible agents such as hepatitis by proper hygiene practices is the responsibility of the leader of the team especially when a physician has the greatest fund of knowledge on the consequences of these preventable infections. I was absolutely appalled at the many examples of technicians and nurses breeching hygiene standards on a daily basis knowing that their actions were placing me at risk of contracting hepatitis C. I could really care less if I am not at all a popular patient in any of the units that I spoke up when I saw faulty care, even as a patient, I knew that the medical license I carried in my pocket mandated that I could not remain silent when I saw nurses and technicians not providing proper care.

If I assumed that level of leadership role as a physician-patient by moral obligation of my professional knowledge to prevent harm to all patients, I am flabbergasted that nephrologists are just now talking about how to assume the leadership role in the dialysis unit that they by this admission had previously abdicated. Perhaps if they had already been in charge, I could have lived out my first two years of dialysis with less stress to me and my wife because I spoke up and refused to allow shoddy work around me. That my friends is the professional duty that I learned in my training and felt a moral obligation to act upon what I knew was right and what was wrong. Isn't that what true leadership is all about?

[Anna Bennett Meinuk@aol.com]

Dear Peter,

Dr. Wasser only lost his license to operate a dialysis unit in the state of NY (and I believe that there is an appeal (I could be wrong on that)) As far as his medical license, he is licensed to practice medicine in NY State.

Per the NYS Online verification I ran tonight:
Name : WASSER WALTER G
Address : NEW YORK NY
Profession : MEDICINE
License No: 133256
Date of Licensure : 12/16/77
Additional Qualification :
Status : REGISTERED
Registered through last day of : 08/11
Medical School: ALBERT EINSTEIN MED COL Degree Date : 06/02/1976

Sadly, DaVita, with their bad policies and procedures, poor staffing practices and profit motivated dispensing of medical care was not censured in any form for the tragedy of DaVita Life Care Dialysis. (well, it was closed, so they will lose future profits - but the majority of the patients were transferred to other DaVita facilities (even when there were closer independents available)

Dr. Wasser is guilty of poor judgment in picking DaVita as his "Partner" in his already well established unit. He made a deal with the devil, and his reputation is paying for it.

A dialysis unit is only as good as all it's staff. When DaVita hires at the bottom of the market salary (Part-time shift workers just a few steps above counter person at McDonalds on the pay scale @ $15.41 an hour), and only staffs one RN per shift for a 30 chair unit, patients suffer, disease spreads, and people die.

The DaVita Stockholders were not hurt by Life Care or Lufkin, there are plenty more mothers, fathers, sisters, brothers with CKD5 to keep the industry in profit, and DaVita has a well established business model - especially if they cut staff and cut corners.