This weekend my wife and I visited some friends in Santa Barbara who are supporters of The Music Academy of the West. The Academy was founded by a group of artists and patrons in 1947 to “…aid in the development of gifted young classical musicians through advanced study with accomplished faculty artists.…” The Academy has evolved and now has its own campus where each summer more than 130 fellows participate through a combination of personal instruction, educational programs and live performances before small or large audiences. Guest faculty includes some of the icons of the music world, such as vocalist Marilyn Horne, opera legend Kiri Te Kanawa, violinist Gil Shaham, pianist Ingrid Fliter, and percussionist Colin Currie. Underlying it all is a strong culture of mentoring, as there is in training for a professional music career even while in school.

Participating students are experiencing this incredible summer experience while on hiatus from New England Conservatory, Juilliard, The Cleveland Institute of Music, Manhattan School of Music, Eastman School of Music and many other prestigious institutions. As I read through each student biography, I was struck by the fact that not only was the person’s school listed, but the key teacher with whom each student worked was identified as well. Mentoring. I had a chance not only to listen to solo, ensemble and orchestra performances, but also to talk to some of the students about their dreams for the future. There was a sense of wonder, of anticipation, of passion about the career for which they were preparing that inspired me. But it also made me think about my own career and the future of nephrology.

This was not the first time I was introspective about the need to re-examine nephrology as a discipline; to rethink how we attract the best and the brightest to the specialty and create opportunities for young doctors to see why nephrology, and improving the lives of kidney patients, is a noble, desirable career. In 2004 my colleagues and I published the results of a survey we took of 67 fellows participating in an advanced perceptorship in nephrology.¹ We found that exposure to hemodialysis and peritoneal dialysis was pathetic, with 50% of fellows reporting fewer than three months of exposure to in-center hemodialysis ICHD, often without didactic sessions or regular attending rounds) and 25% no exposure at all to peritoneal dialysis. This mirrored concerns expressed by many more than 10 years previously. ^2-4

Well, here we are, another 8 years later and has the situation improved? Three recent articles address this issue. Merighi et al. attempted to study the relationship between nephrology training experience and subsequent clinical practice. ⁵ Using a national survey, data from 2010 provided insights into the experience of over 600 nephrologists. Nearly 40% of respondents answered they did not feel well prepared for the care of dialysis patients at the end of their fellowship. In addition, although over 90% of dialysis patients in the US utilize ICHD, only 6% of the nephrologists surveyed would choose this modality for themselves.

Is this just a problem with training programs or is it a problem with the expectations residents have as they consider nephrology as a career? Shah et al. have tried to address this question in a fascinating study published recently. ⁶ Over 50% of the time nephrology was chosen prior to the second year of medical residency training, in half of these individuals during medical school or before. While the majority chose nephrology because of the interesting subject material, only 65% reported that mentoring or a role model was influential in the decision. A disappointing 64% were extremely or very satisfied about their career choice; however, the most common reason for high levels of satisfaction was mentoring.

So, how can the torch of nephrology be brightened, enhancing interest in the specialty, attracting the best and the brightest who can drive innovation in outcomes for our patients? Jhaveri et al. have proposed an interesting elective experience for medical residents that is an important step in the right direction.⁷ While there are many creative components to this approach, enhanced mentoring is an important component.

The theme is inescapable: if we really want to attract the nephrologists we would like to care for our families and ourselves, we need to focus on role models and mentors who are passionate about nephrology, about service to patients and about innovating to improve outcomes. If we can instill these cultural values in young physicians early in their career decision-making process, we can perhaps begin to build the discipline of nephrology to new greatness.

As Robert Frost said,

“I am not a teacher, but an awakener.”

It is incumbent on all of use to awaken the passion in students and colleagues to build the discipline our patients deserve.

Plutarch, over 2000 years ago, said it best:

“The mind is not a vessel to be filled, but a fire to be kindled.”

Striving to bring quality to life,
Allen R. Nissenson, MD

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1. Nissenson AR et al. Improving Outcomes in CKD and ESRD Patients: Carrying the Torch from Training to Practice. Semin in Dial 17:380, 2004.
2. Fine LG. A Proposal to Improve the Attractiveness of Nephrology as a Subspecialty Choice for Residents in Internal Medicine. Am J Kidney Dis 15:302, 1990.
3. Nissenson AR. Morbidity and Mortality of United States Dialysis Patients. The Legacy of Inadequate Nephrologist Training? Semin in Dial 5:277, 1992.
4. Kimmel PL et al. Effectiveness of Renal Fellowship Training for Subsequent Clinical Practice. Am J Kidney Dis 18:249, 1991.
5. Merighi JR et al. Insights into Nephrologist Training, Clinical Practice, and Dialysis Choice. Hemodial Internat 16:242, 2012.
6. Shah HH et al. Career Choice Selection and Satisfaction among US Adult Nephrology Fellows. www.cjasn.org Vol 7 September, 2012.
7. Jhaveri KD et al. Enhancing Interest in Nephrology Careers During Medical Residency, in press. http://dx.doi.org/10.1053/j.ajkd.2012.04.020.

I am sitting here on Father’s Day and reminiscing about my father. He was born in 1919 into a struggling first-generation immigrant family in Chicago. Over the years he worked hard, as folks who lived through the Great Depression and World War II did in those days, and became a successful businessman. He taught me many things, but above all the importance of interpersonal relationships and the value, the imperative, of always treating everyone with respect and dignity—from your bosses to the housekeepers. This value serves me well, as it did him. He died in 1998 after a short but terrible battle with pancreatic cancer. My mother, to whom he had been married for 54 years, was devastated but eventually bounced back. She is now 86 and in an independent-living apartment—incredibly, totally cognitively intact, but with multiple medical issues, some of which I have previously mentioned in my blogs.

The recent Time Magazine article by Joe Klein, “The Long Goodbye,” (1)got me thinking about the issue of how we as a society approach the impending deaths of loved ones. Klein points out how lucky he and his parents were to get into the Geisinger system, where patient-centric, integrated and holistic care was provided and his parents were cared for, as he would like to be. He states, “Doctors are trained to do whatever they can to save a patient, even an elderly one, and that is an excellent thing. But that Hippocratic impulse has been subtly undermined by the rewards of fee-for-service medicine and by the threat of malpractice suits, which militate in favor of ordering the extra MRI or blood test or dialysis even for a patient who probably has only weeks to live.…” A few days later Austin Considine, writing in The New York Times, noted that Klein was only one of many who have recently written on this topic, with articles in New York magazine and The Atlantic Monthly in the past year articulating the same themes (2). The managing editor of Time, Richard Stengel, notes, “[this is] an issue that’s always on people’s minds…every day there are thousands and thousands of people making these agonizing life-and-death decisions.”

These musings by noted popular writers were brought into focus for me, not because of the frailty of my mother’s medical condition, but by an outstanding article in the recent American Journal of Kidney Disease by Jane Schell and colleagues: Discussions of the Kidney Disease Trajectory by Elderly Patients and Nephrologists: A Qualitative Study (3). The purpose of the article was to better understand with whom nephrologists and elderly patients interact and discuss the future at various stages of kidney disease. The results are fascinating and worth summarizing.

Schell developed a process map of the progress of kidney disease, from diagnosis to disease progression to treatment preparation to dialysis to end of life. She then was able to identify, through questionnaires and interviews, themes for patients and nephrologists at each of these steps. For patients, Schell’s process map indicated diagnosis leads to shock, and then, as treatment preparation begins, patients are quite uncertain about how the disease will progress. As dialysis and further clinical deterioration occur, patients express a lack of readiness for living with dialysis and facing death. For nephrologists, Schell noted there is a real struggle initially to explain how complex kidney disease is, and a real feeling of frustration with the lack of control over the progression of the disease. As dialysis is initiated and clinical deterioration occurs, nephrologists tend to avoid discussions of the future. So what is missing here? We have a failure to communicate! As Schell concludes, “This study shows key areas within nephrologist-patient communication amenable to interventions that address patient understanding and treatment decision making. Effective communication has been shown to enhance patient understanding, shared decision making, and implementation of care plans consistent with patient preferences and goals.… These data show the gaps that exist in how nephrologists and elderly patients discuss and understand the kidney disease course. Interventions that focus on addressing emotion, uncertainty, and understanding may improve patients’ experiences. Effective communication may enhance patient-centered care and promote greater shared decision making.”

It is no coincidence that the recent RPA Clinical Practice Guideline is titled “Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis.” In order to share, one must communicate. Seeing frail, elderly patients in the office quarterly or the dialysis facility only once monthly is insufficient to permit the relationship-building, the establishment of trust, that is essential for true, deep discussions of these personal but critical issues.

Francis Weld Peabody was a distinguished clinician and teacher, educated at Harvard and Johns Hopkins in the early 20th century. His words first published in JAMA nearly a century ago still ring true:

“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.… One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

Striving to bring quality to life,

Allen R. Nissenson, MD
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1. Klein J. Time Magazine, June 11, 2012.
2. Considine A. The New York Times, June 13, 2012.
3. Schell J.O., et al. AJKD 59:495, 2012.

On May 21, 2012, DaVita^® and HealthCare Partners announced a merger agreement: “DaVita Inc…a leading provider of kidney care services for those diagnosed with chronic kidney disease (CKD), and HealthCare Partners, the country’s largest operator of medical groups and physician networks, announced today that they have entered into a definitive merger agreement. The two companies expect to close the transaction early in the fourth quarter of this year. Upon closing, the combined company will be named DaVita HealthCare Partners Inc.” To those of us from DaVita and HealthCare Partners who have had the vision of delivering holistic, integrated, patient-centric, high-quality, efficient and effective care to the citizens of America, this is an opportunity of a lifetime.

Over 20 years ago Kent Thiry, CEO of DaVita Inc., had a vision about integrated coordinated care while he was president of Vivra, Inc. Over the subsequent years he never lost this vision, and he brought it with him to DaVita when he took the reins of a floundering Total Renal Care and turned it into the incredible organization that is now DaVita. At DaVita, we strive to be the greatest healthcare community the world has ever seen.

Nearly as long ago a group of nephrologists, led by the dynamic and charismatic John Dickmeyer from the Bay Area of San Francisco, along with an incredibly accomplished and experienced nurse, Jan Nielsen, convinced Baxter Healthcare that ESRD patient care was a mess—highly fragmented and badly in need of innovative new approaches. I was fortunate enough to be part of this group that included Alan Hull, Ted Steinman, Dick Glassock, Tom Parker, Brian Pereira and Allan Collins, among others. It was an exciting time and with Baxter’s support we launched RMS Disease Management and then RMS Lifeline, the latter operating freestanding vascular-access centers. We demonstrated that care coordination for ESRD patients could improve outcomes and lower overall costs of care, but we were restricted to working with health plans since there was no mechanism to apply our approaches to fee-for-service Medicare patients.

In 2005 the stars aligned: Baxter was ready to get out of the service businesses and RMS Disease Management and RMS Lifeline were sold to DaVita. Kent clearly was further laying the foundation for his dream from years before at Vivra. RMS Disease Management continues to operate within DaVita as VillageHealth®, driving holistic, coordinated care of thousands of health-plan patients. In a recent CMS demonstration project, VillageHealth showed that integrated care management improved clinical outcomes, lowering mortality and hospitalizations, while also lowering the total costs of care.

Around the same time that Kent was striving to realize his vision of integrated care delivery at Vivra, and shortly before we began our quest with RMS Disease Management, two outstanding physician groups in California formed HealthCare Partners (HCP). The group named Dr. Bob Margolis managing partner and CEO and developed into one of the more highly respected organizations and medical groups in the country. Dr. Margolis assembled an outstanding team of physician leaders who have extended the reach of HCP out of Southern California and into Nevada and Florida. HCP is now responsible for the care of nearly 700,000 patients; directly and indirectly employs through affiliated medical groups over 700 physicians; contracts with more than 7,000 physicians; and operates medical offices, pharmacies, urgent-care centers, ambulatory surgery centers and primary-care facilities. HCP is considered a model of healthcare delivery and resource stewardship by many physicians, patients, health plans and regulators, and even some members of Congress. The vision of HCP is “We will be the role model for integrated and coordinated care, leading the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all.” Sound familiar?

A successful partnership takes more than a shared vision and a shared commitment. It requires a shared mission and shared values. DaVita’s mission is to be the provider, partner and employer of choice. Our core values are Service Excellence, Integrity, Team, Continuous Improvement, Accountability, Fulfillment and Fun. For HCP, the mission is “We will partner with our patients to live life to the fullest by providing outstanding healthcare and supporting our physicians to excel in the healing arts.” The values are accountability, collaborative teamwork, the common good, compassionate healing, dignity, excellence, leadership, physician leadership, stewardship, integrity and learning. Two organizations having  comparable vision, mission and values is quite remarkable; each organization is unique and each has tremendous strengths, and together we can make great things happen.

We are embarking on a great adventure and we are not naïve about the challenges we face. The stakes are high and the challenges are great, but the potential to truly make a difference in the lives of millions of Americans will always sustain us in the effort. We don’t know what the future of this endeavor will be, but as Stephen Covey said,

“The best way you can predict your future is to create it.”

There is much work ahead of us to make our shared vision a reality, but we must never forget the words of former President Bill Clinton:

“The future is not an inheritance; it is an opportunity and an obligation.”

We embrace the opportunity and the obligation with great humility, but with optimism that we can make a difference!

Striving to bring quality to life,

Allen R. Nissenson, MD
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Additional Information About the Proposed Transaction and Where to Find It:

In connection with the Merger, DaVita intends to file with the SEC a Registration Statement on Form S-4 to register the DaVita Common Stock issuable in the Merger. Investors and security holders are urged to read the S-4 and any other relevant documents to be filed with the SEC because they will contain important information about DaVita and HCP and the proposed transaction. Investors and security holders may obtain a free copy of the S-4 and other documents when filed by DaVita with the SEC at www.sec.gov or www.davita.com.

A recent article in The Wall Street Journal describes “The Simple Idea That Is Transforming Health Care”-focusing medical providers on patient quality of life (QOL) and integrated and holistic care.  The article provides example after example of how a focus on patient-centric approaches to care, if applied appropriately can be the driver of the metrics that are more typically viewed by health plans and regulators, such as mortality and hospitalization. While the concept that optimizing QOL is an important goal in life and in medical care is intuitive, does apply well to patients with chronic illnesses, and if so, are we in nephrology sufficiently engaged in this effort?

The segment of the American public with chronic illness is growing as the population ages and as obesity, diabetes and hypertension all increase in prevalence. We have seen the results, of course, in the continuing growth of incident ESRD patients, two-thirds of whom have diabetes and or hypertension as a cause or complication of kidney disease. We as a renal community have continued to pursue the more traditional metrics of outcomes success -and not even very rigorously since we are tracking and being held accountable primarily for intermediate or surrogate outcomes such as dialysis adequacy, anemia, and so on. Although standardized mortality and hospitalization ratios (SMR and SHR) are also available, the value and accuracy of these is open to debate because the key to the standardization is the “expected” mortality/hospitalization rate and the elements that are considered in that calculation. There have been no publications independently verifying the accuracy of SMR or SHR in this population.

For many years we have been focusing on patient-centric care at DaVita, including through our disease management group VillageHealth®. An integral component of the VillageHealth program is the patient activation measure (PAM) which gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare. The PAM assessment segments patients into one of four progressively higher activation levels. Each level addresses a broad array of self-care behaviors and offers insight into the characteristics that drive health behaviors.

Activated patients are fully engaged as participants in their care, are more adherent with medications and other aspects of care, and have lower hospitalization rates, better survival, and higher QOL.

We have recently conducted extensive surveys and focus groups with patients to better understand what is important to them when they are getting ESRD care. I expected that great clinical outcomes like fewer catheters and outstanding phosphorus levels would be near the top of the list. However,  none of the clinical outcomes came close to the desire of patients to be treated as human beings -for caregivers to truly treat them holistically, to care about them as people and about their families to understand what is important to them and to help them achieve their life goals.

The challenge of responding to these needs is considerable. The current standardized instruments we have for assessing QOL, including the KDQOL, are imperfect and as shown recently by Tracy Mayne, an international authority in this area and a member of DaVita Clinical Research® (DCR®). KDQOL cannot be validated as truly predictive of QOL with current ESRD patients. While the search for a reliable, reproducible, valid instrument to measure QOL goes on, we all need to commit to the importance of this area.

Nephrologists, as leaders of the healthcare team for our patients, need to be sensitive to the integrated and holistic needs of patients and be role models for other members of the team. All caregivers need to believe that hitting QIP targets or other quality metrics is important, but caring about the patient as a person is at least as, if not more, important. We should all encourage our patients to take advantage of the full range of tools to increase their empowerment.

We have developed a teaching program for CKD patients (KidneySmart™), have a website for ESRD patients and have dedicated social workers who focus every day on helping patients have their hopes and dreams known and fulfilled to the extent possible. But these tools are not enough unless we are all willing to make a paradigm shift in the way we think about what is really important in the lives of these vulnerable and fragile patients.

Some time ago the clinical leadership at DaVita® began a journey to understand and then address how we can truly make a difference in our patients’ lives. It all starts with a vision, and I now state this vision under my signature on every email I send, just to remind me:   “Advancing Integrated and Holistic Care to Realize the Vision of Our Village”.

As Hippocrates said over 2500 years ago:

“It is more important to know what sort of person has a disease than to know what sort of disease a person has.”

Striving to bring quality to life,
Allen R. Nissenson, MD
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I recently had a chance to round on some in-center dialysis patients at my facility at UCLA. It was incredibly heartwarming to see so many of my former patients still doing so well. It was a real homecoming for me. As I made rounds with Fellows and the entire interdisciplinary team, I started to reflect on what it meant to be a leader in a complex healthcare-delivery setting. There is no setting in medicine that better reflects the need for leadership than care in the dialysis facility. So what are the components of a true leader—things we never learned in medical school, but that are so critically important for our patients as we serve as leaders in dialysis facilities? Each person needs to determine what he or she truly believes struck a chord. Our leadership is based on our belief in truth, grace, growth and freedom. Beliefs determine behavior that defines performance as a leader.

Truth involves standards, honesty, discipline, integrity and clear expectations; grace is not a religious reference but includes showing others that you are on their side, that you have empathy, compassion and understanding; growth is characterized by demanding feedback, being self-aware, understanding others, and having humility and discipline; freedom means being encouraging and secure, and forgiving and empowering others—it leads to serving others, and true power comes from giving power to others.

You need to define what you believe as a leader, but these are right on for me. To be true to yourself, evaluate your leadership: 1) The gap: how far are you from where you want to be?; 2) The fit: how do I fit my role?; 3) Feedback: what do others say?; 4) Parallel context: how are others in similar roles doing?

Sound like a business-school exercise? Sound irrelevant to the day-to-day grind of a nephrologist/Medical Director? Think again. Leadership is demanded of nephrologists, and such leaders will not only have great dialysis facilities with incredible patient outcomes, but will also have successful practices and fulfilling lives.

One of the great things about DaVita is the incorporation of core values into everything that is done in the organization. As I made rounds I had a true epiphany—the way I conduct myself is exactly the articulation of the DaVita core values! I first and foremost am committed to enable high quality of care by serving my patients and delivering service excellence. To be a true leader and be trusted by colleagues and patients and their families, this service excellence must be delivered with the greatest integrity; we say what we believe and we do what we say. Delivering credible, excellent care cannot be done by one individual, but requires a team working together with a common vision to improve the lives of patients with kidney disease. We must, of course, never be satisfied with where we are, but rather must always strive for continuous improvement. We also must be humble and understand that none of us is always right, and we must be willing to ensure that accountability for one’s own actions is something we insist upon from our colleagues and our patients. If we can drive excellent service, in a transparent way with full integrity, working with a team, continuously improving and holding ourselves accountable, then we can experience true fulfillment while still having fun in the process. Is this an achievable vision? I would submit yes—I am living it!

So, stepping up and being a leader, while always anchored by fundamental core values, is for me the way to do the best I can for my patients and to live the most fulfilling life possible. Are you a leader? What are your core values? Take some time to answer those questions. It might just be the most valuable time you have spent in your hectic life as a nephrologist.

Remember what the great management guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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Allen R. Nissenson, MD, FACP, Chief Medical Officer, DaVita
Dr. Nissenson explains Accountable Care Organizations (ACOs) in more detail and the clinical care opportunities for the kidney community.

For more information on the future of Accountable Care Organizations visit www.AccountableKidneyCare.com

In this short video, Allen R. Nissenson, MD, FACP, Chief Medical Officer, DaVita, shares why taking the proper care of the kidney population is so important for Integrated Care Systems or ACOs.

Disclaimer: The views expressed in this presentation are the views of the speaker and do not necessarily reflect the views of DaVita, Inc. DaVita does not guarantee the accuracy of the data included in this presentation.

In 1972, during the term of President Richard Nixon, the House of Representatives was working on a revision of the 1965 Medicare and Medicaid programs. The work of the House was nearly completed when an amendment was proposed and passed, Section 299I of Public Law 92-603, titled: “Chronic Renal Disease Considered to Constitute Disability.” The amendment added the following short phrase to the list of eligibility criteria for Medicare entitlement: “[an individual who] is medically determined to have chronic renal disease and who requires hemodialysis or renal transplantation for such disease.” The bill was passed on October 30, 1972, and the program was enacted on July 1, 1973.

So, 2012 is the 40th anniversary of that historic amendment, which ensured access to kidney care for thousands of people. Although this is not the precise birthday, I was compelled to write this blog because of a front-page article in the Sunday New York Times on Feb. 18. The headline read: “60 Lives, 30 Kidneys, All Linked: Intricate Balancing Act Produces a Record Chain of Transplants.” In the article, the domino chain–transplantation approach is explained. It is truly remarkable how many lives have been changed by this approach, which is increasingly necessary because of the massive shortage of available donor organs.

What caught my eye in the article, however, were some characterizations of dialysis: “Since receiving a diagnosis of diabetes-related renal disease in his mid-40s, he had endured the burning and bloating and dismal tedium of dialysis for nearly a year”; “Only half of dialysis patients survive more than three years”; “Many of the 400,000 Americans who are tethered [italics mine] to dialysis”; “Dialysis … saps the productivity of caregivers as well as of patients.” OK, anyone who has cared for dialysis patients knows that being on dialysis is difficult, and none of us is satisfied with the clinical outcomes or quality of life of our patients, but how often do we or our patients reflect on how far we have come, not just on how long and difficult the road ahead remains?

Thomas Graham is generally regarded as the first pioneer of diffusion-based dialysis. Working as a chemist in Scotland in the 19th century, Graham separated substances using a semipermeable membrane. Over the next century, many innovators contributed to the development of modern dialysis, including John Abel, Leonard Rowntree and Benjamin Turner; Georg Haas; Willem Kolff; and of course Belding Scribner. It was the incredible work of Scribner’s Seattle team that made chronic dialysis possible and a reality.

Here we are in the early 21st century and have the shoulders of such giants on which to stand. The promise of continuously operating, wearable dialysis devices is no longer a dream but rapidly becoming a reality. Recent research suggests that more frequent and longer treatments offer the hope of enhanced survival, fewer hospitalizations and higher quality of life. Extensive research is underway on in vitro growth of functioning kidney tissue and on reaching the Holy Grail of transplantation — true tolerance. While we wait for such breakthroughs, we would do well as nephrologists to read the inspirational book written by Lori Hartwell, someone who has had a life filled with illness, dialysis and transplantation. Lori’s book is “Chronically Happy: Joyful Living in Spite of Chronic Illness.”

So, happy birthday, Medicare ESRD program. Had you never been born, countless millions would have died of kidney failure. The current dominant treatment, dialysis, is not perfect, but it is continually improving. Those of us entrusted with caring for this fragile group of patients must always remember that we are also treating families and caregivers. The responsibility is enormous, but by working together — doctors, nurses, social workers, dietitians, technicians, families, caregivers and researchers — we can continue to do what is the true calling of medicine: provide holistic, patient-centric care that considers all of the unique attributes of each patient and family and strives to enable all patients to live the life to which they aspire. After all, who won the race, the tortoise or the hare?

Kahlil Gibran provides poignant advice for all of us: “Advance, and never halt, for advancing is perfection. Advance and do not fear the thorns in the path, for they draw only corrupt blood.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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My wife is a maniacal exerciser. Three days a week at the gym, weights and cardio; two days a week, Pilates; Saturday, walk on the beach with a girlfriend; Sunday, walk on the beach with me. Although she comes from a family of women with osteoporosis, she has incredible bone density.

Two weeks ago, we were in Santa Barbara visiting our niece, her husband — a postdoc at University of California–Santa Barbara — and their beautiful five-month old daughter. After a wonderful visit, we took off for a relaxing lunch and stroll in Carpenteria, a few miles south of Santa Barbara on the way home to Los Angeles. We were walking around the main drag when my wife turned to point to a cute shop, tripped, and hit the ground. Her foot immediately began to swell, so we got some ice for the one-hour drive home.

Over the weekend, we treated the foot with ice, heat and liberal painkillers, but by Sunday night we knew that we would need to see an orthopedist for an examination and x-rays. That is when it began to get really painful.

On Monday morning, I contacted the chief of orthopedics at a nearby hospital who had his assistant squeeze my wife in to see someone at noon that day. The administrative assistant who made the arrangements couldn’t have been nicer, and we felt like we were on our way to a resolution. We drove to the new state-of-the-art facility. It was a blustery day, and we had been told that we should drive up to valet parking so we could get a wheelchair to take my wife to the appointment. When we pulled up, the valet said, “Sorry, the garage is full.” I insisted that I needed to help my wife to the appointment; after consulting his colleagues, the valet came back with a ticket and took the car.

We walked to the bank of patient elevators, about a block inside the building, rode to the second floor and arrived to find out they had no record of the appointment. I called the administrative assistant who had made the arrangements, and she got that straightened out: “computer malfunction.” Next was the foot x-ray, with the patient having to navigate two large, heavy doors while holding a “patient notification pager” to get from the waiting room to x-ray. We saw a senior orthopedist, who diagnosed a Lisfranc fracture after the examination and review of the films. He thought an MRI should be done to better see the tendons and determine if a cast or surgery would be best. He wrote the order but said we would get a call in a day or two after the authorization was obtained.

By Wednesday, we hadn’t heard from the office and called — we were told they had the request but only one person in the office was authorized to interact with insurance companies, and she was out. Needless to say, after two additional days of pain and essentially no treatment, my wife was outraged. The office said they would see what they could do and would call us back. We called again on Thursday, and they said that the “insurance person” was still out; the one on the phone said it was not her job, but she would see if she could help and would return our call. When we called Friday morning, after not hearing from anyone on Thursday, we were agitated but glad to hear that the MRI had been authorized. We were instructed to call radiology for an appointment.

When we called, radiology said the earliest appointment was for the following Monday. We were incensed — a painful, though admittedly not life-threatening injury, and another several days before the needed test so that the correct treatment could be started. I again called the chief of orthopedics, and the administrative assistant called back in five minutes to say we could get the MRI at noon that day.

We were grateful, and my wife had a friend take her to the test. After it was completed, she asked the technician to please have the radiologist call the orthopedist with the results as soon as they were ready. He stated that the test was not marked “stat” and would be read the following Monday. When my wife went up to the desk to ask the radiology administrative assistant how to get this expedited, the assistant was sitting at the desk, eating lunch, and said, “There is nothing that can be done. It’s not marked stat, and only the ordering doctor can change that.” A final call to the chief of orthopedics, the MRI was read, and it showed not one but two fractures and the possible need for surgery.

No one could make up a story such as this, but it is all too common in our current healthcare system. None of the individuals involved in my wife’s care was hostile, rude or uncaring. They were all working within a system, however, that does not place value on being patient-centric. Like most of our care delivery system, perhaps with “elite” private and academic health centers the poster-children, it is more about “them” than it is about “us” when we are patients. Building beautiful new facilities and having the latest technology has little value when the system forgets why it exists — to provide compassionate, timely, high-quality care for individuals who are in pain, frightened and at the mercy of the system.

By the way, the fact that I was able to “pull strings” to accomplish even what was eventually done is not something of which I am proud. Like any husband, I was willing to do all that I could to make sure my wife was cared for in the best way possible. I am no different from any other husband, wife, son or daughter who wants only the best for their loved one. No one deserves anything less.

We should always remember that as physicians and healthcare workers, we are here to serve patients. As the founder of modern nursing, Florence Nightingale, said more than a century and a half ago: “Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.”

Apollo 13 returned from moon orbit safely, and I hope we have the wisdom, foresight and ability to work together in teams to rescue our ailing healthcare delivery system.

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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We have to admit — we are coming late to the party! The concept of a culture of safety began outside of healthcare in organizations that self-characterized as “high reliability,” where highly complex and often hazardous activities are a daily reality. Such organizations live and breathe safety from the senior executives to the frontline workers. The Agency for Healthcare Research and Quality (AHRQ) suggests that the following are key features of a successful culture of safety:1

• Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
• A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns

There are national efforts ongoing outside of AHRQ to address safety in healthcare, most notably the National Patient Safety Foundation (NPSF).2 This independent, nonprofit organization was established in 1997 and continues to provide programs to assist organizations in focusing on safety in healthcare. In 2006, a survey was conducted, led by the Renal Physicians Association (RPA), to get insights from patients and professionals on the state of patient safety knowledge and programs in ESRD/dialysis. This effort culminated in an ongoing website, Keeping Kidney Patients Safe, which is a fantastic resource in this area.3

Through the survey mentioned above, key areas of focus were identified, including hand hygiene, patient falls, incorrect dialyzer or solution, medication omissions or errors, non-adherence to procedures and venous needle dislodgement. Clearly, these are important issues of patient safety, and there are likely others that need attention as well. Missing from this list, however, are provider safety issues such as needle punctures. With the shrinking workforce in dialysis, keeping our colleagues in the dialysis facility safe is also an important imperative.

So, how do we implement the culture of safety in our facilities? By making a commitment as nephrologists and medical directors to make this a core part of how we function. The American Association of Kidney Patients (AAKP) has tried to get the patients involved in the effort with their national program, 5 Steps to Safer Health Care, described by Dr. Alan Kliger:4

• Speak up if you have questions or concerns
• Keep a list of all of your medications
• Make sure you get the results of any test or procedures
• Talk with your doctor and healthcare team about your options
• Make sure you understand what will happen if you need surgery

We need to make a commitment as we enter 2012: Establishing a culture of safety in our facilities will be a great gift for our patients and our staff, and we will make it happen! To do this successfully will require reassessment of the systems of care we currently have and a willingness to make the necessary changes.

As recently stated by Dr. Paul Batalden (and possibly attributable to W. Edwards Deming and/or Donald Berwick) of Dartmouth Medical School and the Institute for Healthcare Improvement (IHI):

“Every system is perfectly designed to get the results it gets.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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References:

1.    http://psnet.ahrq.gov
2.    http://www.npsf.org
3.    http://www.kidneypatientsafety.org
4.    http://www.aakp.org