Cause for concern is highlighted as several articles were recently published starting with Robin Fields, Investigative Reporter for Propublica. http://www.propublica.org/topic/diagnosing-dialysis (the most recent in a series was focused on California). Shockwaves ran through the dialysis community with damage control initiated by some dialysis providers, without a degree of transparency stating, ‘yes, we have made mistakes and we will work towards correcting and ensuring our staff are completely educated, trained and supervised”. Patients quickly learning more about the care their dialysis facility provides, along with many advocates, as myself, feeling justified in that which we have been stating for years - improvement is needed in delivery of care for this vulnerable population. Data which was protected, by Centers for Medicare and Medicaid Services (CMS) (agency that oversees dialysis facilities and is suppose to ensure patients receive quality safe care), was finally made public, after two years of trying, thanks to Propublica. There is only one dialysis provider, Northwest Kidney Centers, in the Washington State area, that has made this data available through their website. This data, Dialysis Facility Reports (DFR), provides necessary information that consumers can use in order to make an informed decision and choice of which dialysis facility they want to attend. The provided data on the CMS website, Dialysis Facility Compare (DFC), might show that a facility has good outcomes in three areas, however, many, many times, the survey (inspection) report and the DFR will show quite different. The inspection report clearly shows the day-to-day care that is delivered and this, along with the DFR, is what consumers need in order to make informed decisions and choices about their care and where they receive care. Dialysis facilities are left behind when it comes to real transparency and the question is ‘why?‘. Nursing homes must post their most recent inspection report in a conspicuous place. Additionally, detailed data on nursing homes (quality care components and other factors) can be found on various government websites. Hospitals also have wide ranging information on government websites, including data on reportable preventable errors and infection data. Dialysis facilities are forgotten with only scanty data on government websites e.g. DFC, that does not truly serve the patient in making an informed decision of which facility to choose or to know how their facility rates. Again, the question, “Why?”
Another article released article http://californiawatch.org/dailyreport/nearly-half-dialysis-technicians-failing-skills-test-8265 instills more fear in advocates, patients and their loved ones. Stated in the article, “"Workers who fail can keep working with supervision from other facility staff, and they can take the test as many times as they want." However, who exactly is supervising these staff who fail their test? As an advocate, having recently reviewed the inspection reports (survey findings) from the California Department of Public Health, (CDPH) Licensing & Certification Division (L&C), I must ask, ‘who is directing traffic?’ These surveys conducted from January through August 2010 - www.qualitysafepatientcare.com - clearly reveal that staff, in these dialysis facilities, are not adhering to their own facility policies and procedures. Patients, as a result, are placed in situations of experiencing a potential or actual negative outcome. California has no oversight that mandates any reporting of preventable errors that result in harm or death, therefore, the extent of reasons for harm or death is often unknown.
The newest federal-level regulations mandate that dialysis technicians be certified. Many questions regarding delivery of care arise when we are now told that nearly half of technicians fail the skills test. This includes new technicians and those that have been working for years. Indeed frightening, to say the least. Perhaps this explains and supports that which I, as an advocate, have been stating for almost seven years, “more training and education and supervision is necessary to ensure quality safe care is being delivered”. Then, we must take a look at the regulations (federal) to see that only a GED is required and no medical background is required to become a dialysis technician, who administers a life-sustaining treatment to most of the patients. Many, as myself, believe there is a cookie-cutter training that often does not meet the individual needs of this vulnerable population who also have many other medical conditions. Additionally, after classroom training, staff are placed with a preceptor. Often, this is not the best method because preceptors might not always be available to ensure new staff are correctly implementing procedures or preceptors might not, themselves, be implementing correct procedures. Usually the preceptor is another dialysis technician. I have urged providers, for years, to review their existing training and education programs and ensure that staff have a complete understanding of the rationale for implementing correct practices as well as having a clear understanding of the potential negative outcomes, including death that can result if correct practices are not implemented. Often, I am asked - if staff are aware of correct practices, but do not implement such, is this an intentional act to place a patient in a potential or actual negative outcome situation? The bottom line is that, after reading the surveys conducted, something is greatly amiss in many of these dialysis facilities in California.
Another article recently released “People Will Die, And Other Budget Cut Consequences” http://www.californiaprogressreport.com/site/node/8614 brings forth even greater concern for this vulnerable population. As a Dialysis Patient Safety Advocate, I could only stop, shake my head, and wonder if there is anyone who cares about this vulnerable population, especially after reading the following statement in the article, “People on kidney dialysis will be cut off after ten treatments when they need twelve to fifteen per month. So they will begin to die within 30 days of the implementation of the proposed budget cut.” This is unconscionable, is all I can say. This will result in patients frequenting the hospital emergency departments to have their dialysis treatments, patients experiencing negative outcomes such as fluid overload or increased potassium levels which can result in cardiac and pulmonary events and even death. We are cutting a budget but then placing more financial burden on hospitals, while placing patients in a potentially deadly situation.
Problems with dialysis care and oversight dates back ten years to several Office of Inspector General reports. Centers for Medicare and Medicaid Services (CMS) contracts with California Department of Public Health to inspect facilities every three years. However, many facilities have not been inspected in over 8 years. CMS has not sufficiently funded the state in order to hire more staff to result in timely inspections. CMS is suppose to protect dialysis patients and ensure they receive safe care. As I reviewed surveys that had not been inspected in several years - www.qualitysafepatientcare.com I could only wonder what went on between the last survey and the most recent one, especially when serious deficient practices were identified by the surveyor (inspector). I also wondered why facility management had not identified these problems, as well as how long and how many patients were affected and had negative outcomes. Then, there was yet another issue of the surveyors taking a sample of patients and reviewing their medical records, finding preventable errors. How many non-sampled patients were also affected? Then, I wondered how many surveyors observed deficient practices, during the inspection process, that happened while they were not present. I always found it interesting that dialysis providers had pushed to have their ‘new’ facilities opened timely in order to treat patients, however, never heard anyone push to have their facility inspected timely to ensure compliance with regulations. Interesting. Then, yet, another aspect is that of lack of enforcement of regulations. Basically, the only consequence for the facility, even if a patient has a negative outcome, is the submitting of a written ‘plan of correction’ stating how the problems will be corrected so that it does not happen again. Truly, no protection for patients.
INFECTION, after more than ten years, remains the number two killer of this vulnerable population of dialysis patients. However, when correct practices are implemented, infection can be prevented. As I read through the surveys - www.qualitysafepatientcare.com from January - August 2010, I was shocked to see that 23 of 25 facilities had been cited for deficiencies in infection control, some more serious than others; placing patients in harm’s way. The survey (inspection) findings clearly showed that often staff were aware of correct practices, but did not adhere to such. Surveys continued to show that staff were not fully educated, trained or supervised to ensure implementation of correct facility policies and procedures in infection control. Shocking, because these are basic practices to prevent infection. Training programs might start in the classroom and then move towards working with a preceptor in a facility. However, if the preceptor (usually a dialysis technician) does not implement correct practices (as I have personally observed) then what can we expect? There is no mandatory reporting of infection data in California, as there is for hospitals. Colorado is the only state that mandates infection data reporting to the Center for Disease Control and Prevention (CDC). The CDC has a special program that helps facilities decrease their infection rates. This program, other than Colorado, is voluntary. Hence, I ask, if Colorado can do such to decrease the number of deadly infections patients receive, then why can’t other states. Again, transparency is nil. Consumers have a right to know what their facility infection data is in order to self-protect.
Having communicated with patients and families from all over the United States, including California, the most frequent complaints are that of reprisal, at various degrees, as a result of speaking out to ensure safe care is delivered, asking questions, or questioning that which staff are doing; not being fully educated and included in the team in order to prevent errors (patients, through education can support staff in preventing errors) and not being treated with respect and dignity.
Quality safe patient care is the result of staff implementing correct facility policies and procedures, adequate unit level management to ensure correct practices are implemented and patients being fully educated and involved in their care. Patients should be completely educated in staff practices that will keep them safe e.g. what practices staff will be implementing to prevent infections, how the dialysis machine works, including machine settings. The next step is for staff to encourage patients, if they observe an incorrect practice, to remind staff. This is the beginning of patient-centered care.
Roberta Mikles BA RN
Uncompensated Dialysis Patient Safety Advocate
San Diego, CA
Dialysis Patients - A sad, sad situation, what next?
