Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Clinical Performance Measures 
for Dialysis Facilities 
Practices of the Major Dialysis Corporations 
Supplemental Report # 1 
JANET REHNQUIST 
INSPECTOR GENERAL 
JANUARY 2002 
OEI-01-99-00053  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of

Inspector General.  It conducts short-term management and program evaluations (called

inspections) that focus on issues of concern to the Department, the Congress, and the public.  The

inspection reports provide findings and recommendations on the efficiency, vulnerability, and

effectiveness of departmental programs. 

OEI's Boston office prepared this report under the direction of Mark R. Yessian Ph.D., Regional

Inspector General and Joyce M. Greenleaf, M.B.A., Assistant Regional Inspector General. 

Principal OEI staff included:

BOSTON  HEADQUARTERS

Aimee K. Golbitz, Lead Analyst  Bambi D. Straw, Program Specialist

Norman J. Han, Program Analyst

To obtain copies of this report, please call the Boston Regional Office at 617-565-1050. 
Reports are also available on the World Wide Web at our home page address: 
http://oig.hhs.gov/oei/  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To describe how the five largest dialysis corporations use clinical performance measures to 
hold their facilities accountable for the quality of care. 
BACKGROUND 
In our June 2000 report, External Quality Review of Dialysis: A Call for Greater 
Accountability, we urged the Centers for Medicare & Medicaid Services (CMS), formerly 
the Health Care Financing Administration, to use facility-specific clinical performance 
measures as a key part of its oversight of dialysis facilities.  Clinical performance measures 
are quantitative indicators, typically expressed as a percentage, that reflect the quality of 
care patients received.  CMS concurred with the directions we suggested and presented a 
detailed action plan to strengthen its use of clinical performance measures.  Since then it 
has been active in carrying out this plan. 
In this follow-up inquiry, we describe the practices of the five largest dialysis corporations 
in using clinical performance measures to hold their own facilities accountable for the 
quality of care.  This is a significant domain of external quality oversight that we did not 
address in our prior report and that has been largely ignored in the public sphere.  We 
regard an inquiry into this domain as important because: (1) these corporations account 
for approximately 70 percent of all dialysis patients in the United States, the vast majority 
of whom are Medicare beneficiaries, and represent over 2,000 dialysis facilities, (2) they 
have a substantial body of experience in using performance measures, and (3) they have 
gained know-how that can be helpful to CMS and others. 
This report is the first of two supplemental reports focusing on clinical performance 
measures for dialysis facilities.  The main report is entitled Building on the Experiences of 
Dialysis Corporations.  The second supplemental report, Lessons Learned by the Major 
Dialysis Corporations and Implications for Medicare, presents 14 lessons the 
corporations have learned in collecting and using performance measures.  We also make 
several recommendations to the Medicare program and present comments we received 
from CMS and other stakeholders on the draft report.  All three reports are based on our 
review of corporate documents, interviews with corporate medical directors, and visits to 
a number of the corporations dialysis facilities.  We sought to describe their processes and 
did not evaluate the overall effectiveness of their systems.  We did not audit or validate the 
performance data the corporations collect from their facilities.  The corporations 
voluntarily participated in this review and the data presented was self-reported by the 
corporations. 
i
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  CORPORATE PRACTICES 
Dialysis Corporations Rely Heavily on Facility-Specific Performance Measures. 
This reliance has evolved and increased over more than 10 years.  The key corporate 
practices encompass the following: 
Collecting many different measures.  Each corporation collects at least 14 different 
clinical performance measures.  They collect data on all their patients within their facilities, 
usually on a monthly basis. 
Collecting the data electronically.  They collect much of the facility-specific data 
electronically, using several different approaches.  Three collect some data electronically 
from clinical laboratories and two collect data directly from computerized dialysis 
machines; one relies on email to send data files. 
Reviewing the data for accuracy.  They review the data prior to analysis.  The reviews 
most often take place at a central level by a data analyst or statistician. 
Establishing minimum standards.  They have established minimum standards for each 
performance measure.  These standards specify a level below which care is unacceptable. 
If a facility fails to meet the minimum standard, the corporations expect the facility to take 
action to improve. 
Establishing goals.  Three of the corporations have established clinical performance 
goals.  The goals seek to give each facility a higher level of performance to aim for. 
Conducting comparative analysis at the facility level.  Corporations typically compare 
a facility to its own past performance, its region and/or business division, the company as a 
whole, and the nation. 
Disseminating facility-specific reports.  They disseminate facility-specific reports at 
least every quarter.  Two of the corporations disseminate the reports monthly.  By the 
time the facilities receive their reports the data are often less than 3 months old. 
Fostering improvements.  They encourage their facilities to use performance measures to 
foster improvements in dialysis care.  They look to facilities to conduct quality 
improvement projects.  Toward this end, the corporations conduct training, provide 
manuals, and reward top performers. 
Intervening with poor performers.  They use several strategies to intervene with 
facilities that fail to meet minimum performance standards.  First, they seek to determine if 
the data reveal some basis for concern about a facilitys performance.  If they do, then the 
corporations intervene through peer review, training, mandated quality improvement 
projects, or in the most serious cases, termination of facility staff or physicians. 
ii
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  CONCLUSION 
At their own initiative, the five largest dialysis corporations are carrying out a wide range 
of activities intended to make performance measures a vital, ongoing tool of quality 
improvement.  The corporations differ in some of their approaches and emphases, but 
more notable are their similarities.  Each collects a large number of similar performance 
measures, relies largely on electronic reporting, generates facility-specific reports that 
provide comparative assessments, and conducts outreach to help facilities make 
constructive use of the measures.  In our second supplemental report, Clinical 
Performance Measures for Dialysis Facilities: Lessons Learned by the Major Dialysis 
Corporations and Implications for Medicare, we look more closely at the corporate 
practices to identify lessons learned and we also make several recommendations to CMS. 
iii
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CORPORATE PRACTICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Dialysis Corporations Rely Heavily on Facility-Specific Performance Measures . . . . . . . . . . . . .  5

Collecting Many Different Measures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Electronic Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Data Review Process for Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Minimum Standards for Performance Measures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Goals for Performance Measures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Comparative Analysis at the Facility Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Facility-Specific Reports  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Using the Measures to Foster Improvements  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Using the Measures to Intervene with Poor Performers  . . . . . . . . . . . . . . . . . . . . . . . . 10

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12

Appendix A: Glossary of Clinical Performance Measures . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix B: Facility-Specific Performance Measures Collected by the Corporations  . .  13

Appendix C: Comparison of the Corporations Practices  . . . . . . . . . . . . . . . . . . . . . . . 14

Appendix D: Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

iv
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053   CMS Actions 
CMS concurred with the directions we set forth and presented a detailed action plan that 
incorporated numerous efforts it had underway and would be initiating.  It is drafting new 
Conditions for Coverage, Medicare regulations, for dialysis facilities, which it expects to 
release in draft in the coming months.  In doing so, it plans to consider our 
recommendations to strengthen the role of the medical director, to require facilities to 
electronically report on a core set of performance measures, and to require facilities to 
conduct their own quality improvement activities. 
CMS has also committed to strengthening its existing efforts to collect facility-specific 
data on all Medicare beneficiaries as soon as it is able to put into place its new information 
system, Vital Information System for Improvement of Outcomes in Nephrology.5  This 
new information system will allow facilities to electronically report data directly to CMS. 
The system will also help ensure accurate reporting through computer software that will 
contain automatic data edits that will notify the user when data that is illogical is entered. 
CMS has already implemented the Standard Information Management System for the End-
Stage Renal Disease Networks, which connects all the Networks together and directly 
with CMS.  CMS is also revising three administrative data forms that it collects from 
facilities that contain data used to calculate performance measures.  Eventually these 
forms will be submitted to CMS electronically by the facilities. 
Since 1995, CMS, via the End-Stage Renal Disease Networks, has distributed Unit-
Specific Reports that provide comparative, facility-specific data, which includes mortality 
and hospitalization rates.  Facility-specific urea reduction ratio and hematocrit levels were 
added to the reports after 1998.  In January 2001, CMS publicly released comparative 
facility-specific reports that contained three performance measures: urea reduction ratio, 
hematocrit, and mortality.  The reports are available on the Internet.6  In July 2001, CMS 
distributed to State survey agencies, facility-specific reports that also contain key 
performance measures.  State survey agencies use these reports to assist in selecting 
facilities for review and to focus Medicare certification surveys.  Currently the majority of 
the data in these reports comes from Medicare billing and administrative data and the data 
are over 2 years old.  As the CMS implements its Vital Information System for 
Improvement of Outcomes in Nephrology it is expected that the data for these reports will 
be more timely (see appendix B for more detailed information about Federal sources of 
performance data). 
Finally, CMS revised its process to review and approve each of the Networks annual 
quality improvement projects.  The new process is intended to reduce variation in the 
quality of projects and help Networks design more sophisticated projects.  The new 
process also gives Networks more guidance on what topic areas they should focus on for 
their quality improvement projects. 
2
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  Dialysis Corporations Use of Clinical Performance Measures 
In this follow-up inquiry we focus on the experiences of large, corporate dialysis providers 
in using clinical performance measures as a way of holding their own facilities accountable 
for the quality of care provided.  This is a significant domain of external quality oversight 
that we did not address in our prior report and that has been largely ignored in the public 
sphere. 
We regard it as important to learn more about the experiences of these providers for three 
major reasons.  First, as the dialysis industry has consolidated in recent years, these 
corporations have become a major force in the dialysis field.  The five largest 
corporations, which we focus on in this report, now account for about 70 percent of all 
dialysis patients in the United States, the vast majority of whom are Medicare 
beneficiaries.7  They account for over 2,000 of the nations 3,500 dialysis facilities.8 
Second, they have a substantial body of experience in using performance measures to 
monitor the quality of care at their own facilities.  And, third, they have gained know-how 
that may be useful to Federal efforts. 
Methodology 
We limited our inquiry to the five largest providers: Fresenius Medical Care North 
America, Gambro Healthcare, Davita (formerly Total Renal Care), Renal Care Group, and 
Dialysis Clinic, Inc.  In selecting the top five, we do not seek to imply that they are 
necessarily the best in using performance measures, nor to suggest that other corporations 
or independently owned facilities are not also experienced in using such measures.  Each 
of the five corporations participated in our study voluntarily and made available to us 
information concerning its practices.  The information we present is current as of June 
2001.  The information contained in this report was self-reported by the dialysis 
corporations. 
At the outset, we considered including in our review measures that relate to clinical 
performance, patient satisfaction, and adverse events.  Each is important to national policy 
and in each case the corporations have some relevant experience.  However, for this 
inquiry, we decided to limit our focus to clinical performance measures in order to allow 
for greater detail.  Clinical performance measures are the measures that the corporations 
have the most experience with, receive most of their attention, and bear most immediately 
on CMS oversight. 
Our data-gathering methods included two focus groups with the medical directors of the 
five corporations, further interviews with each of the corporate medical directors and 
other corporate officials, visits to several of the corporations dialysis facilities, and 
reviews of pertinent documents of the corporations. 
It is important to underscore that our inquiry is not an evaluation of the corporations 
practices.  They have been carrying out these practices at their own initiative, not in 
3
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  response to any Federal requirements.  We did not seek to assess how well they are using 
performance measures, nor did we obtain sufficient information to make such an 
assessment.  We did not audit or validate the performance data the corporations collect 
from their facilities.  We did seek to gain a clear understanding of their current practices. 
This Report and its Companion Report 
This report is the first of two supplemental reports based on the main report entitled, 
Clinical Performance Measures for Dialysis Facilities: Building on the Experiences of 
the Dialysis Corporations (OEI-01-99-0052).  This first supplemental report offers a 
description of the corporate practices concerning the use of facility-specific performance 
measures.  We address specifics concerning data collection, validation, analysis, 
dissemination, and corporate practices concerning fostering improvement and intervening 
with poor performers. 
The second supplemental report, Clinical Performance Measures for Dialysis Facilities: 
Lessons Learned by the Major Dialysis Corporations and Implications for Medicare 
(OEI-01-99-00054), begins with two lessons associated with establishing a foundation for 
accountability within the dialysis facilities.  It then turns to 12 lessons learned from 
implementing clinical performance measures.  We also make several recommendations to 
CMS.  In this report we include the complete comments we received from CMS and other 
stakeholders on the draft reports in appendix C. 
We conducted this study in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
4
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  C O R P O R A T E   P R A C T I C E S  
Dialysis corporations rely heavily on facility-specific performance 
measures to foster accountability. 
The corporations have been collecting performance measures for more than 10 years. 
They have invested considerably in staff, computers, training, and other resources needed 
to collect and apply facility-specific performance measures.  One corporation estimated its 
annual budget related to using performance measures at around $7 million. 
Corporate officials shared several reasons for investing in performance measures.  One of 
the major reasons was a strong desire to provide top-quality dialysis care.  Performance 
measures allowed them to systematically monitor quality and identify areas for 
improvement.  One corporate official stated, Without the data we are blind.  Another 
reason was that, in the long term, high quality care will lead to increased profitability, 
good care is good business.  Patients that are healthier have fewer hospital stays and live 
longer, and provide more business for the dialysis facility.  They also underscored that 
higher quality of care leads to patient and personnel retention.  Dialysis facilities compete 
intensely for patients, nephrologists, nurses, and other staff.  The corporate representatives 
believed that facilities with a high commitment to quality are better able to attract and 
retain both staff and patients. 
Each corporation collects at least 14 different clinical performance measures. 
Common Dialysis 
The corporations typically collect the data on all the 
Performance Measures 
patients within their facilities, with the exception in some 
cases of those patients in a managed care plan.  The  Urea reduction ratio

measures they collect are familiar to most renal  KT/V

Hematocrit

professionals and capture various clinical aspects of 
Hemoglobin

dialysis treatment.  They include measures that evaluate 
Ferritin level

adequacy of dialysis treatment, anemia management, 
Transferrin saturation

nutritional level, vascular access, bone disease, and  Parathyroid

hypertension (see box and appendix B).  In addition, all  Albumin

the corporations collect data on mortality, hospitalization,  Blood pressure

Hospitalization rate

and the number of missed treatments.  The corporations 
Missed treatments

collect the data regularly, typically on a monthly basis and, 
Mortality rates

in some cases, every treatment. 
Peritonitis rates

Vascular access

Clotting events

Transplantation rate

Creatinine clearance

See appendix A for a

glossary of terms.

5
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  The corporations collect much of the facility-specific data electronically, using 
several different approaches. 
The corporations use a combination of several strategies to collect data.  To a varying 
extent all the corporations still rely on paper forms for some data elements, especially 
mortality and hospitalization.  But the majority of measures are collected electronically. 
Three corporations collect some performance measures, such as KT/V or hemoglobin, 
directly from the laboratories, thereby eliminating any need for facility staff to enter or 
transmit these values.  The lab enters the data and the company downloads it.  Two of the 
corporations collect several measures, such as time of dialysis and blood pressure, directly 
from computerized dialysis machines.  The corporation can then download the data at any 
time, thereby eliminating the need for any manual entry by facility staff.  One corporation 
installed computer terminals at each dialysis treatment station, thereby allowing the nurses 
to manually enter data at the time of treatment.  Later the data is downloaded into the 
companys central database.  Similarly, electronic medical records allow for certain items 
to be abstracted and downloaded by a central repository.  Finally, one company simply has 
its facilities email an attached data file to a central repository. 
But even electronic data submission still requires someone to enter the data into the 
system in the first place.  Most often this responsibility was left to the nurses.  It was rare 
that a dialysis facility had a full-time person dedicated to data entry. 
The corporations review the data for accuracy prior to analysis. 
Each of the five corporations has a process in place to review the data.  The reviews most 
often take place at a central level where all the data can be reviewed at once.  All have 
full-time data analysts or statisticians at the central level that regularly monitor the data 
provided by the facilities.  One corporate medical director told us that he spends a 
considerable amount of his time on the phone with facilities asking questions about the 
data to ensure its accuracy.  When information is missing or seems questionable, the data 
analyst or statistician verifies or obtains the missing information from the facility.  The 
corporations also rely on software programs for data analysis that have automatic data 
edits built in that prevent illogical data from being included in analysis. 
Some of the corporations have also devised tools to help the facilities review the data 
themselves for accuracy at the local level prior to submitting it to a central location for 
analysis.  One corporation provides a checklist detailing common errors to look for in each 
individual performance measure.  Another corporation has each facility administrator and 
unit secretary review the data.  The corporations have also built into their computer 
software program for data entry, automatic edits so that the facility nurse who happens to 
type 12 for a KT/V value instead of 1.2 is alerted and can immediately correct it. 
Several of the corporations provide facility-specific data audit reports that show the 
number of missing values and the percentages of errors. 
6
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053   Three of the corporations have also established clinical performance goals. 
Goals differ from minimums in that they set a higher bar.  Corporations established the goals to 
encourage all facilities to improve.  In the cases where a facility achieved the goals, corporations 
would often recognized that facility in some way, such as with an award or a bonus to the staff. 
Like minimum standards, expert committees established the goals.  One company 
established its goals by using the values achieved by the top 10 percent of its facilities. 
Another corporation stated that its goal is to have 100 percent of its patient meet the 
target values set for each measure. 
All the corporations conduct comparative analysis of the performance measures 
at the facility level. 
The corporations conduct analysis of all facility data at a central level.  They have full-time 
staff to analyze facility data and create facility-specific reports.  The most routine type of 
analysis performed is comparisons.  The facility-specific reports show an individual 
facilitys performance compared with its own past performance, its regions performance, 
its business divisions performance, and its company-wide performance.  (The figure 
below is an excerpt from one corporations facility-specific report on the clinical 
performance measure the urea reduction ratio.  It shows how four facilities compare to 
their own past performance, and other facilities in their region.  The dotted line represents 
the minimum performance standard.)  Another corporation lists the percentile the facility is 
in for each clinical performance measure on its reports. 
Excerpt From a Corporations Facility-Specific Report 
8
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  Along with the results of the individual facilities, the corporations analyze the data at the regional 
or business division level and at a company-wide level.  These reports show how each region or 
business division is meeting the stated clinical performance measure targets set by the corporation. 
Some of the corporations even compare the company-wide performance with the nation.  For 
national clinical performance data the corporations rely on data collected by CMS.10 
All of the corporations disseminate facility-specific reports at least every quarter. 
Two of the corporations disseminate their facility-specific reports monthly and the 
remaining three disseminate their reports quarterly.  By the time the facilities receive their 
own report, the data is often less than 3 months old and in some cases just weeks old. 
Four of the corporations disseminate facility-specific reports through their corporate 
computer network.  Once the reports are on the networks they can be accessed by facility 
medical directors, facility administrators, nurses and other key personnel at any time.  One 
corporation has its facility-specific reports on the web, allowing physicians to log in from 
any computer connected to the Internet, enter their passwords, and see a facilitys clinical 
performance measures. 
Currently, none of the corporations make its facility-specific reports routinely available to 
the public.  However, at least two of the companies indicated that if a patient requests 
facility-specific performance measures, they would share them.  Some aggregate data on 
the companys performance as a whole is often available through public financial reports. 
One corporation routinely makes public aggregate data on the companys performance as 
a whole through various corporate publications. 
The corporations encourage all their facilities to use their performance measures 
to foster improvement in dialysis care. 
None of the corporations simply collect and disseminate the data.  The corporations have 
built a support and accountability infrastructure to maximize the effectiveness of the 
measures.  The corporations encourage all their facilities to conduct quality improvement 
projects, designed and implemented at the facility level.  To foster this goal, all the 
corporations have developed training programs and materials for facility staff regarding 
the use of performance measures.  These programs and materials help educate nurses and 
physicians about performance measures in general, how to interpret their facilities results, 
and how to develop a plan of action to improve.  The companies conduct many of these 
training sessions in central locations and sometimes the corporations conduct specialized 
training for just one facility.  The training sessions tend to be interactive and focused on 
actual case examples so that, by the end of the training session, the participants have a 
plan they can implement at their facility. 
Corporations also encourage the facilities to use the data in other ways besides training. 
One corporation regularly holds conference calls that physicians, nurses, and other 
9
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  facility staff can call in and share their success stories or ask questions.  All the 
corporations have devised tools to help facilities conduct various quality improvement 
projects.  These tools include how-to guides, worksheets, and best practices.  Finally, 
some of the corporations conduct corporate-wide improvement projects. 
All the corporations have devised ways to reward top performers.  Some of the 
corporations compensate the medical directors based on how well their facility meets the 
corporate performance measurements.  In addition, several corporations rank their 
facilities based on various performance measures and recognize the best overall with a 
luncheon and/or staff bonuses. 
Corporations use several strategies to intervene with facilities that continually fail 
to meet minimum standards. 
Corporations tend to intervene if a facility performance continually declines on several 
performance measures, continually fails to improve on its performance measures, or the 
performance measures suggest a problem that is an immediate threat to patient lives.  But, 
prior to intervening, the corporations will try to confirm that the data are accurately 
depicting the quality of care.  This is often done by examining the patient population, 
complaints, results of State surveys, recent patient satisfaction surveys, and adverse 
events.  In doing so, the corporations are trying to rule out that other factors such as 
patient demographics or comorbidities do not account for performance measures. 
Although all the corporations risk adjust some of their data, they are unable to account for 
everything.  A facility could have poor outcomes because it has sicker patients. 
The corporations first look to peer review when they need to intervene with a facility. 
They have committees of regional medical directors that analyze the facilitys clinical 
performance measures.  The committee discusses with the facilitys medical director why 
the facility is not meeting the minimums and how to improve performance.  Along with 
this collegial approach, corporations may require the facility to submit a continuous 
quality improvement project to address the specific problem that is adversely affecting its 
performance.  Corporations also have a quality team comprised of doctors, nurses, 
dieticians, and social workers who work with the facility in a peer-to-peer manner. 
When peer review fails, many of the corporations start to work with the facility on site. 
One corporation sends a group of clinicians to the facility and actually evaluates how well 
the facility has addressed the problem.  Another corporation also sends a similar team to 
the facility and conducts a mock Medicare certification survey of the facility. 
Another approach is to involve the corporate medical director.  One corporation requires 
the medical director meet with the chief corporate medical director to formally discuss the 
facilitys performance.  Another corporation sends a letter outlining the facilitys 
deficiencies and asks the facilitys medical director to start addressing the problems. 
Finally, corporations can remove a medical director or an attending physician from the 
clinic. 
10
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  C O N C L U S I O N  
At their own initiative, the major dialysis corporations are making significant commitments 
to using clinical performance measures as tools of quality improvement.  While our review 
did not seek to assess how effective their efforts have been to date, it did make clear that 
their current practices cover a wide range of activities that are crucial to improving the 
quality of care and that parallel in fundamental ways activities that CMS is undertaking as 
part of its national leadership.  Our review also made clear that the corporations have 
developed a considerable body of experience on the dos and donts of performance 
measurement. 
Among the five corporations there are some differences in approaches and emphases, but 
what impressed us much more was the similarities.  Each of them collects a large number 
of measures (by and large the same), relies largely on electronic reporting, generates 
timely, facility-specific reports that compare a facilitys performance with other facilities 
and its own past performance, and conducts outreach to urge and help individual facilities 
to commit themselves to quality improvement projects (see appendix C). 
In our second report, Clinical Performance Measures for Dialysis Facilities: Lessons 
Learned by the Major Dialysis Corporations and Implications for Medicare (OEI-01-99-
00054), we delve more deeply into the corporate practices to identify the lessons that flow 
from them.  We also provide several recommendations to CMS as it fosters the use of 
performance measures to improve the quality of dialysis care. 
11
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  APPENDIX A 
Glossary of Clinical Performance Measures For Dialysis 
Albumin: A measure of the level of proteins in the blood, used to monitor the level of nutrition. 
Anemia: Inadequate red blood cells, a common concern among dialysis patients that can lead to extreme 
fatigue and other complications. 
Catheter: A type of vascular access. A tube placed in a patients blood vessel, primarily used for 
temporary access to the blood stream. 
Clotting events: Arteriovenous fistulas, both native and synthetic, can become clotted with the patients 
blood causing complications for the dialysis patient. 
Creatinine clearance: A measure used to determine adequacy in peritoneal patients. Creatinine 
clearance measures the removal of the protein creatine from the body. 
Ferritin level: A measure of the level of iron stored within the body. 
Hematocrit: A measure of the ratio of red blood cells to the plasma volume. Used to monitor anemia. 
Hemoglobin: A measure of the amount of a specific protein in red blood cells that carries oxygen. Used 
to monitor anemia. 
KT/V: A function of the amount of urea removed multiplied by the time on dialysis, divided by the 
volume of urea distribution, or approximately the amount of water in the body. Used to monitor the 
adequacy of the dialysis treatment. 
Native arteriovenous (AV) fistula. A type of vascular access. A patients own artery and vein are 
surgically joined to allow arterial blood to flow through a vein, usually placed in the forearm and takes 
several weeks to mature. 
Parathyroid: A hormone that regulates calcium and phosphorus and is used to monitor bone disease. 
Peritonitis: An inflammation of the peritoneum, a membrane that lines the stomach, that can occur in 
individuals receiving peritoneal dialysis. 
Synthetic arteriovenous (AV) graft: A type of vascular access. A synthetic blood vessel is used to 
surgically join the patients artery and vein, usually placed in the forearm and takes several weeks to 
mature. 
Transferrin saturation (TSAT): A measure of iron immediately available to produce red blood cells. 
Used to manage and monitor anemia in dialysis patients. 
Urea reduction ratio (URR): A measure of the amount of urea removed during dialysis, as determined 
by pre- and post-dialysis blood urea nitrogen levels. Used to monitor the adequacy of dialysis treatment. 
Vascular access: The point of direct access to the blood stream for hemodialysis. There are three types: 
catheter, native arteriovenous fistula, and synthetic arteriovenous graft. 
12
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053   APPENDIX C 
Comparison of the Dialysis Corporations Practices in Collecting and 
Using Facility-Specific Clinical Performance Measures 
Company  Compan  Compan  Compan  Compan  CMS 
#1  y  y  y  y 
#2  #3  #4  #5 
Years of experience in collecting facility-specific  10+  20+  10+  20+  5  10+ 
performance measures 
Percentage of patients within a facility for which  100%  100%  100%  100%*  100%  All 
measures are collected  Medicare 
Patients 
Data collected electronically from dialysis machine  no  no  yes  no  yes  no 
Data submitted electronically from the facility  yes  yes  yes  yes  yes  no 
Data collected electronically from labs  yes  no  yes  yes  no  no 
Frequency of data collection  monthly  monthly  by  monthly  monthly  varies 
treatment 
Frequency of dissemination of facility-specific  monthly  quarterly  monthly  quarterly  monthly  annually 
performance reports 
Age of data by time it is disseminated  less than 4  1 day to 12  1-3 weeks  6-7 weeks  4 weeks  ~3 years 
weeks  weeks 
Main format for facility-specific reports  intranet  intranet  intranet  intranet and  intranet and  internet and 
mail  mail  mail 
Compares the facility to its region  yes  yes  yes  yes  yes  yes 
Compares the facility to the past  yes  yes  yes  yes  yes  yes 
Compares the facility to the company  yes  yes  yes  yes  yes  NA** 
Compares the facility to the entire nation  yes  yes  yes  yes  yes  yes 
Compares the facility to a minimum standard  yes  yes  yes  yes  yes  yes 
Compensation for the facility medical directors is  no  no  no  yes  yes  NA** 
tied to performance measures 
Facility-specific clinical performance measures are  no  no  no  no  no  some 
routinely publicly available 
Provide physician-specific reports  yes  no  yes  no  yes***  no 
*except for patients in managed care plans, **not applicable, *** only for facility medical directors 
14
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  APPENDIX D 
Endnotes 
1.  Dialysis is the process of removing toxins from the body by diffusion across a semipermeable 
membrane, thereby compensating for kidney failure.  There are two types of dialysis: hemodialysis 
and peritoneal dialysis.  Hemodialysis involves the removal of toxins directly from the patients 
blood stream, requiring direct access to the bloodstream.  The patients blood is cycled through an 
artificial kidney, an external machine, that removes the toxins and excess fluids from the blood. 
The artificial kidney machine uses a semipermeable membrane, called a hemodialyzer, to filter out 
the toxins from the blood.  Peritoneal dialysis utilizes the patients natural peritoneal membrane, 
located in the abdominal cavity, to remove toxins and excess fluids. 
2.  The 2001 USRDS Annual Data Report Reference Tables, The United States Renal Data 
System, Section J.  Accessed via the Internet at [http://www.usrds.org/reference.htm]. 
3.  The End-Stage Renal Disease Networks, established in 1976, are CMS main contractors for 
monitoring dialysis facilities, as they are entirely focused on dialysis facilities.  CMS relies on the 
18 regional Networks to collect data from facilities, conduct annual quality improvement projects, 
and evaluate and resolve complaints.  The main mission of the Networks as set out in the Statute 
is to ensure effective and efficient administration of the benefits provided under the end-stage 
renal disease program.  Section 1881(c) of the Social Security Act. 
4.  CMS contracts with the State survey agencies, typically within departments of public health, to 
conduct on-site Medicare certification surveys of facilities and to investigate complaints, both in 
accordance with Medicare Conditions for Coverage for dialysis facilities. 
5.  Department of Health and Human Services, Office of Inspector General, External Quality 
Review of Dialysis Facilities: A Call for Greater Accountability, OEI-01-99-00050, June 2000, 
page 47. 
6.  See [http://www.medicare.gov/Dialysis/Home.asp]. 
7.  Based on figures from, The Ten Largest Renal Providers, Nephrology News and Issues, 
Vol. 15 No. 8, July 2001 p. 30, and The 2001 USRDS Annual Data Report Reference Tables, 
The United States Renal Data  System, Section J.  Accessed via the Internet at 
[http://www.usrds.org/reference.htm]. 
8.  Ibid. 
9.  See the following website for the targets established by the National Kidney Foundation, 
[http://www.kidney.org/professionals/doqi/index.cfm]. 
10.  CMS collects several key clinical performance measures through billing and administrative 
forms.  They are urea reduction ratio, hematocrit, mortality, and hospitalization.  Facilities 
15
Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053  APPENDIX D 
typically submit these billing forms electronically to fiscal intermediaries that process Medicare 
claims submitted by the facilities, and then pass the data on to CMS. 
CMS also collects over 16 clinical performance measures for its Clinical Performance Measures 
Project through the End-Stage Renal Disease Networks on a national sample of Medicare 
beneficiaries each year.  The measures include the KT/V, urea reduction ratio, serum albumin, and 
hemoglobin.  Facilities submit the data on paper forms to the Networks.  Networks enter the data 
into CMS data system.  The Networks validate a sample of the data. 
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Dialysis: Practices of the Major Dialysis Corporations   OEI-01-99-00053