Improving adequacy of hemodialysis in Northern California ESRD patients: a final project report. Provider Participants and Medical Review Board of the TransPacific Renal Network.

The National Core Indicators Project, initiated in 1994, has brought progressive changes in adequacy of dialysis for end-stage renal disease (ESRD) patients in the TransPacific Renal Network and across the United States. The 1998 Core Indicator Project showed each Network's standing for percentage of patients with urea reduction ratio (URR) > or = 0.65 and average URR. The TransPacific Renal Network ranked 12(th) among the 18 Networks for this adequacy measure. The goals of this project were to improve the Network standing in the United States for the percent of patients with URR > or = 0.65, eliminate or reduce the barriers to achieving adequate dialysis, and evaluate URR versus KT/V data and the variances occurring with these measures. In January 1999, data were collected from all 113 Northern California hemodialysis facilities for quarter 4, 1998, to evaluate adequacy. Each facility provided patient population (N) for KT/V and URR samples, facility averages for KT/V and URR, number of patients with KT/V > or = 1.2 and URR > or = 0.65, and data on post-blood-urea-nitrogen (BUN) sampling methods. A random selection of 10% (12) providers with data below the US and Network standards was selected for an intensive assessment. Using baseline measurements, on-site data were collected from a random selection of the patient population. Chart data were reviewed, analyzed, and discussed in an exit interview with the facility management. On-site visits were performed in July/June 1999. The primary focus included adequacy data and process of care that affect adequacy outcomes, concurrent review of patients receiving treatment at the time of the site visit, and general medical record review. In Phase I, only 12 facilities showed an average URR below 0.65. All facilities reported an average KT/V greater than the DOQI target of 1.2. Forty-two facilities had their percentage of patients with a URR below the national benchmark; only 18 facilities had their percentage of patients with a KT/V below the national benchmark. Only 9% (n = 8) of the 113 providers had a variance in post-BUN sampling methodologies that could be related to the clinical measure of adequacy. In Phase II, a random selection of 12 providers with data below US and Network standards was made for an intensive assessment. A total of 217 patient records were reviewed from a population of 1,027. In addition to comparison of baseline data, each facility was assessed for barriers to achieving adequacy outcomes. The number of problems was extensive and specific to each facility; however, a common reoccurring theme in the majority of events was the lack of supporting documentation for changes to the plan of care when variances occur. The most common occurrences were incorrect blood flow and dialysate flow with no supporting documentation on record for the prescription not being met. In Phase III, Network interventions for facilities not meeting US and Network standards for adequacy as measured by URR and KT/V included required quarterly reporting on their facility-specific quality improvement programs for adequacy. In addition the 12 facilities that participated in the intensive assessment had additional interventions that included an educational "tool box" focused on documentation, legal implications of charting, and general medical records management, and an educational program to review information to be shared with facility staff. All on-site facilities reported ongoing quality improvement programs. In some facilities they did provide a focus on processes and not only a measurement of an indicator. All facilities reported a team concept of some type used in their program. Although there were similarities in the facilities, each facility presented with a unique combination of barriers. In addition to a large patient-to-RN ratio, the lack of technical education for the unlicensed assistive personnel on processes and outcomes appears to play a significant role in the achievement of