COMPLIANCE AUDIT PROGRAM

Overview
The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) continues in its efforts to promote voluntarily developed and implemented compliance programs for the health care industry. Standards have been developed or accepted by the federal government to promote performance levels necessary to insure patient safety in the outpatient dialysis facility. Compliance with these standards is necessary to receive and maintain Medicare certification and subsequently Medicare reimbursement.
The frequency of surveys has been increasing over the past decade and that trend will continue. Large dialysis companies have compliance officers to assist their facilities at the local level to prepare for surveys. HDS provides a Medicare compliance program and mock survey to help dialysis providers prepare for the Medicare survey. Through an extensive library of clinical and technical manuals HDS can assist a dialysis provider in achieving compliance with federal and state regulations. HDS resource manuals include:

• Patient Care Policies And Procedures
• Infection Control Policies And Procedures
• Nursing Policies And Procedures
• Technical Policies And Procedures
• Quality Assurance Performance Improvement Policies And Procedures
• Emergency Preparedness Policies And Procedures
• Personnel Policies And Procedures

Renal Disease Management

Large for-profit dialysis companies are positioning themselves to become the national leader of renal services across the United States.  They see the profits in the future under global capitation residing in the Renal Accountable Care Organization that operates the integrated renal delivery systems throughout the U.S. Hospitals, nephrologists, dialysis providers, and ancillary providers become cost centers under the renal ACO thus savings would be controlled by the owner(s) of the ACO.

Ultimately a hospital based dialysis program must evolve its renal product line into a renal disease management program which would allow key providers in the hospital’s provider network to work directly with patients and families across the continuum of the disease.  This process assists in arranging and managing the complex set of resources that the patient requires to maintain health and independent functioning.  Through enhanced coordination of care the renal program would have an opportunity to achieve the maximum cost-effective use of resources and will position its’ program for future reimbursement under a shared savings paradigm.

A Care Management Program offers a focused approach to patient care that coordinates resources across the entire health care delivery system and throughout the life cycle of a disease whereby the payor, patient, and provider assume accountability in the management of the patient’s chronic illness. Care Management of patients with Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) utilizes tools and resources that are (1) led by the nephrologist, (2) coordinated, monitored and evaluated by the Renal Care Coordinator, and (3) applied by the care management team.

In order to manage the cost of inpatient services provided to CKD and ESRD patients, hospitals must establish a platform upon which the key providers of renal services approach renal failure as a spectrum of disease.  The system should follow the patient from first presentation with early stage chronic renal failure through to dialysis and/or transplantation, and death.  Renal care coordinators should be used to promote a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the patient’s individual needs based on risk assessment and the utilization of interdisciplinary care plans. Provision for health maintenance should be formalized into care plans with an emphasis on disability prevention and rehabilitation services.

HDS assist hospitals in the implementation of a Renal Care Management Program that focuses on the unique needs of the ESRD and CKD patient. Through this collaboration operational processes and procedures can be defined that will promote:

• Effective management of significant complications and comorbidities of dialysis (e.g., anemia, infections, hospitalizations etc.).
• Efficient management of patient care across care settings (e.g. inpatient, outpatient, skilled nursing)
• Efficient use of resources (e.g., appropriate use of Erythropoietin Stimulating Agents, elimination of duplicative laboratory testing).
• Coordinate care among the treating physicians including primary care physicians, nephrologists, and other health care specialists.
• Integrate the vascular surgeon into the care continuum by providing outcomes and utilizing the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI) standards for vascular access in the dialysis patient
• Focus on optimal outcomes and develop strategies for the best possible patient car techniques
• Assist each patient with attaining maximum independence and quality of life
• Develop and implement processes to monitor quality of care
• Develop and implement processes to measure satisfaction in all participants
• Continually track and report services delivered to patients and their resulting outcomes
• Develop Quality Improvement (QI) initiatives to improve satisfaction with disease management program

Hemodialysis Staff Training (RN and Patient Care Technician)

HDS offers a comprehensive Hemodialysis Staff Training program that utilizes a customized manual developed to be used with a series of specially designed power point presentations. Power point allows students to visualize many of the concepts and procedures discussed. The combination of the print material and the presentations provides reinforcement-an important component of learning.
To obtain as much as possible from the program, the student should become familiar with and understand the following:

1. OBJECTIVES.
Judging the quality of a learning experience is difficult; however, a test of quality can be made by determining whether or not it has brought about the desired change in a learner’s behavior. Because of this, learning objectives precede each section of material. Clear and precise objectives make evaluation possible, thus, the quality and effectiveness of the learning experience can be determined. The two types of objectives utilized in this program are cognitive and effective.

Cognitive objectives are concerned with knowledge and comprehension. These objectives indicate what the student should be able to do upon completion of the specific section (e.g., identify, define, explain, etc.). The effective objective is concerned with how the student should organize, conceptualize, value, and respond to specific situations upon completion of the section. Together, these objectives give precise direction regarding the subject content and the attitude which you are expected to develop.

2. SELF-EVALUATION.
Questions related to the material follow each section. By completing the self-evaluations the student will know whether or not he/she understood the material accurately. The answers to the self-evaluations will be provided during class.

3. ASSESSMENT.
Formal assessment is accomplished by (1) classroom power point presentation and student participation, (2) written examinations and situational tests, and (3) instructor evaluation.

Written examinations and situational tests are given periodically during the training program. These help the instructor and the student determine his/her ability to make the proper application of the material learned.

A final evaluation by the instructor may be verbal as well as written: It will assess the student’s performance during the training period.

4. PROCESS.
First, the student is to read and study the written material. Second, in the class room the instructor will present to the student the power point segment relating to the written material.

5. SUCCESSFUL COMPLETION OF THE PROGRAM.
The student will complete a total of 80 hours of classroom study – 64 hours the first two weeks and 16 hours during the eight week clinical training. At the end of the week in the clinical area, the preceptor will complete a Weekly Preceptor Evaluation, during which the student will have an opportunity to comment on his/her progress. Upon the completion of the eight week clinical training, the preceptor will complete the Hemodialysis Skills Competency Checklist.

On week eight of the clinical training, the instructor will meet with the student for a minimum of two hours to a conduct a verbal evaluation of the didactic and clinical lessons covered over the course of training. Final completion of this course will include successful demonstration documented on the Skill Competency Checklist by the preceptor and a passing score on the written final exam of 75% or better.
In addition to the training manual and materials, HDS can conduct the 80 hour didactic training on site at the Client’s location of choice; however, to insure compliance with training objectives, the HDS instructor will conduct a two day workshop with the preceptor(s) chosen to work with the student(s) during the clinical rotation. During this workshop the preceptors will participate in a condensed version of the training program designed to ensure that the cognitive and effective objectives outlined in the training are met during the clinical rotation.

Advanced Dialysis Workshop

HDS offers an eight hour advanced dialysis workshop designed to enhance the knowledge base of the experienced dialysis nurse and patient care technician. Topics covered during the workshop include:

Anatomy and Physiology of the Kidney

• Excretory Functions
• Endocrine Functions
• Fluid and Electrolyte Management
• Acid Base Balance

Chronic Kidney Disease

• Overview
• Frequent Co-morbidities
• Classifications and Stages of Chronic Renal Disease

Principles of Dialysis

• Dialysate
• Fluid Removal
• The Dialysis Machine

Assessment of the Dialysis Patient

• Weight
• Blood Pressure
• Pulse
• Respiration
• Temperature
• Communication

Factors that Influence a Patient’s Response to Hemodialysis

• Role of Sodium in Hemodialysis
• Limitations of Fluid Removal
• The Influence of Dialysis on the Determinants of Blood Pressure
• Blood Volume
• Decreasing Blood Osmolality
• Total Peripheral Resistance
• Myocardial Contractility
• Vascular Access

Water Treatment Preparation

• Water Quality Requirements
• Equipment Requirements
• Disinfection Systems

Common Risks and Side Effects Associated with Dialysis

• Hypotension
• Dialysis Disequilibrium
• Nausea and Vomiting
• Cramping
• Headaches
• Arrhythmias
• Chest Pain
• Fever and Chills
• Pruritis
• Restlessness and Insomnia
• Complications of anticoagulant
• Anaphylactic Reactions
• Metabolic Acidosis
• Hypoxemia
• Air Embolism
• Hemolysis

Vascular Access

• Placement
• Complications
• Performance Standards

Clinical Management of the Dialysis Patient

• Multidisciplinary Care Team
• Comprehensive Patient Assessment
• Plan of Care
• Criteria for Stable versus Unstable

Quality Assurance Performace Improvement (QAPI)

• Purpose
• QAPI Committee
• Quality Incentive Program
• Performance Measures

Infection Control Precautions for Dialysis Centers

• Universal Precautions
• Prevention of the Spread of Blood Borne Diseases
• VRE and MRSA Precautions for Dialysis Centers