NN&I - August 2010

Subscribe to our free eNewsletter at www.nephronline.comAugust 2010 Nephrology News & Issues 7 Mr. Neumann has been editor of Nephrology News & Issues since 1989.FIRST WORDBy Mark E. NeumannWe can do better Certainly, there were telltale signs that we needed to. The landmark Morbidity and Mortality Conference in 1989 defined our status among other countries around the world when it came to dialysis care: poor. (The 20th anniversary of this meeting last April concluded that we still have plenty of work to do.) In 1991, the Institute of Medicine (IOM) released a report that said the ESRD Program needed a $350 to $600 million infusion to improve the quality of care, including offering lifetime immunosuppressive coverage for transplant patients (still an unmet goal almost 20 years later). The IOM Committee set several goals for quality improvement, say -ing the ESRD Program needed to "provide care of high quality that achieves desirable health outcomes" based on the patient's condition and our knowledge base. Those goals included: improve clinic surveys and the \037 training of surveyors evaluate all policies, including \037 reimbursement policies, for their impact on the quality of patient care (something the Government Accountability Office recently called for when the upcoming payment bundle is implemented next year). provide adequate support for \037 quality assurance by including costs in dialysis reimbursement develop community-designed \037 quality assurance systems support quality assurance \037 research It is pretty clear that the Centers for Medicare & Medicaid Services did not heed the IOM's suggestion to include funding for quality assur -ance activities in the bundle; instead, most would argue, pay for perfor -mance is quite the opposite: Dialysis clinics need to invest in their own quality improvement tracking sys -tems, and provide reams of data (via CROWNWeb) to prove they are pro-viding good quality care. It's called pay for performance: the better your quality measures look, the more you get rewarded. The good thing is that the renal community had a hand in defining the clinical performance measures. And more are on the way, with cath-eter infec-tions and fluid overload manage-ment being at the top of the list. Berwick's role CMS's' new administrator, Donald M. Berwick, MD, has been touted as the father of continuous quality improvement. In his book, Curing Health Care: New Strategies for Quality Improvement, published in 1990, a reviewer noted: "Donald Berwick is the most clearly heard evangelist of applying industri -al methods of continuous quality improvement to health care." Berwick's approach to improv -ing care, and CMS' fiscal mindset to both improve quality and reign in expenditures, should ultimately prove beneficial to the patientand to the industry as a whole. But CMS has to pay for a job well done. Applied for the right reasons, CQI can benefit patients and the ESRD ProgramContinuous quality improvement, or CQI. Three words that most people try to practice everyday. Whether you are a truck driver, waitress, salesperson, or in our industry, it's a good goal to have. Do your job better so you are more efficient and more effective. CQI really caught on in health care during the 1990s. It wasn't just about improving how you did your job; it was about looking at your patient in a different way: as your customer. In essence, individuals with kidney disease needed a ser-vice, just like someone looking for a good mechanic or, a good meal. If you want that customer to come back and buy your services again, treat them with the best possible care and do the job right. Quality a late bloomer For years, the Health Care Financing Administration spent most of its energy focused on man-aging cost containment. The ESRD Program was a federal entitle -ment conceived by Congress based on naïve estimates of its potential growth. Expenditures skyrocket -ed because of a rapidly expanding patient population. The best HCFA could do was to put a lid on costs by cutting the composite rate and re-inventing the failing payment for -mulas for drugs. No one paid much attention to quality, and the agency had little expertise in how to mea-sure it anyway. FirstWord_NNI0810_3.indd 7 7/20/10 1:56:43 PM