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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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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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

Ezekiel Emanuel is the oldest of three brothers, his younger brother Rahm is Mayor of Chicago and Ari is an agent in Hollywood.  Ezekiel is a physician, a bioethicist who has recently devoted his career to public policy.  He has been writing a series of editorials in the New York Times that outline his view of the current state of healthcare in the U.S. and approaches to addressing the disparities in access to care, the lack of health insurance for millions and, the real elephant in the room, the growing population of patients with multiple chronic conditions that is driving the overall expenditures on healthcare toward 18 percent of the gross domestic product (GDP).

It is this latter group that is most concerning. Representing 10percent of the population, these patients consume nearly two-thirds of all healthcare dollars.  One of the solutions suggested by Dr. Emanuel is to “bundle” payments to providers.  As he explains:  “…The idea is to force all of a patient’s care providers to work together.  They have a strong incentive to eliminate unnecessary tests and treatments and use less expensive implants, drugs and devices that don’t compromise quality, and to prevent infections and other complications that could land the patient back in the hospital…[This is] even more important…for patients with chronic illnesses…these conditions have clear, widely accepted clinical guidelines…that could form the basis for bundled payment…”

This should all sound familiar to nephrologists.  Patients with ESRD comprise less than one percent of all Medicare patients but account for nearly eight percent of all Medicare costs.  Payment for dialysis care has been bundled since nearly the inception of the program and recent changes in the reimbursement system have extended the bundle to include injectable medications, and an expanded list of laboratory tests.  If one closely examines the overall costs of dialysis patient care, however, it is clear that the current bundled payment does nothing to address the most important driver of overall costs- hospitalizations.  In fact, hospitalizations and rehospitalizations account for over 40% of the total costs of care for dialysis patients.  So does this mean that Dr. Emanuel’s concept is wrong – that bundled payments for the chronically ill are not effective in controlling costs and driving higher quality care?

Clearly the devil is in the details.  The current bundled payment system for dialysis services, by focusing on what is “dialysis-related” is inadequate to test the Emanuel hypothesis.  In fact, the renal community has already proven that bundling payments can drive better outcomes and constrain costs of care.  The recently completed CMS Demonstration Project clearly showed that by fully bundling payment to the provider, enabling the provider to invest in holistic, integrated and coordinated care to improve patient health and avoid unnecessary hospitalizations, a true win-win is created.  Patients have better outcomes and the healthcare system costs are constrained.  The most recent movement in healthcare toward ACOs is an acknowledgment by policy makers and providers that bundling payment and creating aligned incentives make sense for patients and the overall system.  Unfortunately, efforts by the renal community to persuade CMS to allow ACOs with attribution of patients because of the presence with kidney disease did not prevail, and there is great concern that our patients will be lost in a general ACO.  We hope that the Centers for Medicare and Medicaid Innovation will be more willing to allow us to build on the great success we have shown in demonstration projects in order to benefit the lives of many more of our patients.

As Thomas Edison said:  “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.”  Nearly a century later politicians and patients are demanding a true health care system rather than a sick care system, and for those with patients with kidney disease, it is time we stepped up and provided just such an approach.

I look forward to your comments, until next time.

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

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As an avid Kindle reader and someone who is often an early adopter of new technology, I was delighted to see the announcement recently that the Kindle Fire had arrived and would be an innovative addition to the growing field of e-readers and tablet electronic devices. Look out, iPad! New innovation drives more and better ideas, right? Innovative thinking results in more choices and a true push for value. This is the American way!

Nephrology has been left in the dust of innovation. Let’s take in-center hemodialysis and the technology to deliver it. Have there been substantive improvements in available equipment during the past decades, or have they been incremental? Is there competition among manufacturers sufficient to drive creativity, or is it just nibbling at the margins?

How about home dialysis therapy? Peritoneal dialysis (PD) is still performed the way it was developed more than 30 years ago with limited new approaches or technology. For home hemodialysis, equipment was created specifically to address this need. But wouldn’t it be even better if there were competitive products from which to choose that provided different features and pricing?

The lack of innovation spills over into the necessary pharmaceuticals that patients on dialysis need. Life-enhancing and clinically important medications — such as erythropoiesis-stimulating agents (ESAs), calcimimetics and others — have driven improvements in patient outcomes, but the lack of innovation and high development costs are particularly problematic in an age when publicly funded healthcare, not to mention the overall economy, is in serious trouble.

Innovation in medicine overall and nephrology in particular not only involves technology and medications but also care delivery models. Nephrologists are embedded in a fee-for-service reimbursement system that rewards individual care interactions and inhibits attempts to consider patient needs holistically. In addition, the ability to invest in proactive care that drives health rather than treating episodes of disease is severely constrained.

If at the end of the day we physicians must step up as true advocates for our patients and drive the best outcomes while stewarding the precious public funds (and trust), we need to advocate for:

     1.    Creating incentives for device and pharmaceutical manufacturers to want to innovate in the area of chronic
            kidney disease (CKD).

     2.    Easing the barriers that keep innovative equipment and medications that are widely used elsewhere in the world
            from being brought to the United States.

     3.    Aggressively pursuing creative care delivery models that include integrated and holistic care and an alignment
            of clinical and financial incentives.

     4.    Promoting collaboration with appropriate federal agencies to ensure that the comparative effectiveness of new
            delivery approaches, devices and pharmaceuticals is assessed, and when a new approach is demonstrated to
            add value, it is approved and appropriate reimbursement for its use is established.

As the innovator and philosopher Buckminster Fuller said, “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”

I look forward to your comments, until next time.

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

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The New York Times published an article recently about the increasing trend of nurses getting advanced degrees. “[In 2010] 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates.”(1)   The concerns expressed by a variety of groups in organized medicine was over the use of the title “doctor” for the nurses who had earned a PhD, with possible confusion of patients over who was a “real” doctor. Clearly this is a smokescreen and the real concern is over control and concern over the slow “intrusion” of nurses into medical practice. This concern is curious since it is clear that there continues to be a significant workforce deficit in primary care and in medical subspecialties such as nephrology.

Recent data from the Renal Physicians Association confirms what all practicing nephrologists already know: The patient population with ESRD and CKD is growing and is increasingly medically complex; the ability to recruit new nephrologists into practices is decreasing, with stagnant training programs and large numbers of IMGs not remaining in practice in the U.S. following training; there is increasing demand on time for administrative activities, including fulfilling the requirements of the Conditions for Coverage to carry out Medical Director activities appropriately; continued pressure from hospitals and other organized care systems to become salaried physicians; and constant downward pressure on reimbursement for physician services. All in all, working harder for less. It is time we applied the age-old adage, work smarter, not harder, and embraced ways of doing this, like working in teams and expanding the use of our advanced nurse colleagues.

There is no area in medicine where the interdisciplinary team (IDT) is as critical to optimizing clinical outcomes as it is in ESRD. Most people, however, narrowly define the IDT as the physician and various teammates in the facility (nurse, technician, dietitian and social worker). This narrow paradigm is critical for driving outcomes, as we showed in a recent publication. (2) When we looked at process measures that significantly correlated with survival at a facility level, IDT meetings were critical, particularly following sentinel events like hospitalizations. That is fine as far as it goes, but it is now apparent that this is necessary, but not sufficient to get the best outcomes.

Focusing on the holistic needs of the ESRD patient is essential, as demonstrated in the recently completed CMS ESRD Demonstration project.(3)  Attention to preventative care, including immunizations, control of diabetes, fluid overload and aggressive medication management all lead to better overall outcomes. But who is going to relentless pursue these things? The nephrologist?  The dialysis facility core team? We need to expand the definition of the IDT to include additional members, such as advanced practice nurses who cannot replace the nephrologist, but can enhance the team by addressing these key areas of care. If we do, we will truly be walking the walk of team, and our patients will be far better off— withbetter clinical outcomes and higher satisfaction with their care.

If we as nephrologists are to fulfill our responsibilities as leaders of dialysis facilities and clinical care for our vulnerable patients we should remember what the organizations 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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The prospective payment system for dialysis services has been in effect since January 1, 2011. Included in the payment starting in 2012 is a 2% withhold to create a pool of money to fund a Quality Incentive Program (QIP). If facilities meet identified quality metrics related to hemoglobin (percent of patients with hemoglobin <10 g/dL; percent of patients with hemoglobin >12g/dL) and adequacy (percent of patients with URR≥65%) they may earn back the 2% withhold. There is no reward for outstanding or superior performance—the best performers get back the payment they would have received prior to the QIP being developed. While structurally this approach has been shown repeatedly to be a poor driver of improved outcomes, it is the one we have currently and the renal community has actively engaged CMS in trying to make it as effective and transparent a program as possible.

The playing field shifted drastically in June, however, when the FDA announced a new label for erythropoietic stimulating agents (ESAs) after a long negotiating process with Amgen. The new label was designed to stress safety—the black box now says that one should not target a hemoglobin >11g/dL (formerly 12g/dL), for example. On the low hemoglobin end, however, many clinicians and patients were surprised by the removal of any lower limit of hemoglobin target. The combination of these two changes essentially altered the entire paradigm of anemia management, with the elimination of any target hemoglobin range, and the recommendation that individualization of therapy was key—decisions to be made by clinicians and patients on a case-by-case basis.

CMS has quickly followed the FDA lead by announcing preliminary rules for QIP going forward, eliminating the hemoglobin <10g/dL metric to conform to the new label.  Many in the renal community, including patient groups and advocates, as well as provider group are concerned that we must all keep our eye on the low hemoglobin ball. Even though we can debate what the safe/appropriate lower hemoglobin level is, it is clear that a return to the days of severe anemia seen prior to 1989 and the introduction of EPO would be undesirable. So the renal community is trying to convince CMS to at least collect data on and report outcomes for low hemoglobin, until such time as sufficient data is amassed to allow return of a low hemoglobin metric for payment in the QIP.

Physician groups have been staunch supporters of this approach and have been strong advocates for focusing on patient safety at the extremes of hemoglobin levels. This is not only because the first and foremost responsibility of physicians is to do no harm, but it is the physicians who decide, after discussion with their patients, what hemoglobin to target, and how much EPO (and iron) is needed to achieve this hemoglobin. This puts some physicians in an awkward and uncomfortable position, trying to always maintain their role as patient advocates when evidence for benefit and harm is unclear or changing. In addition, they must be appropriate stewards of the public trust, in this case, largely Medicare resources when decisions involve costly treatments.

The challenge to practicing physicians is to be able to follow the lead of physician organizations and accept our role as the arbiter at the intersection of quality care and costs of care. The area of anemia management brings this right to the forefront, where costly therapy and a lack of clarity on the hard evidence of risk versus harm is front and center. A recent article by Bob Brook of Rand brings this issue front and center (Brook RH.  The role of physicians in controlling medical care costs and reducing waste.  JAMA 306:  650-651, 2011). Dr. Brook is one of the gurus of health outcomes research and has pioneered the use of medical evidence to determine how best to treat individual patients as well as populations. With our shrinking healthcare budget, can we justify treating all patients to a hemoglobin of 11 or higher? Would that be the best use of resources, some of which could be better spent on other more impactful care? Similarly, undertreating anemia is also wasteful—patients are more likely to require costly, and at times morbid, blood transfusions or to be hospitalized for complications of anemia. The human cost in terms of quality of life is also potentially huge.

It is clear that the way out of this conundrum is not a one-size-fits-all approach to patient care, but one that minimizes variation in care that is harmful and costly, while addressing the needs of each individual patient. Only a physician can do the latter, while collaboration between physician and provider, with use of protocols and algorithms, can achieve the former. We need to all be held accountable for the outcomes that derive from these approaches.

As the renowned lawyer Louis Nizer said, “When a man points a finger at someone else, he should remember that four of his fingers are pointing at himself.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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