Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Clinical Performance Measures 
for Dialysis Facilities 
Building on the Experiences 
of the Dialysis Corporations 
JANET REHNQUIST 
INSPECTOR GENERAL 
JANUARY 2002 
OEI-01-99-00052  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 AND BACKGROUND 
To present lessons learned by the five largest dialysis corporations in using clinical 
performance measures to hold facilities accountable for the quality of care and to address 
the implications they have for the Centers for Medicare & Medicaid Services (CMS). 
This is the main report in the series Clinical Performance Measures for Dialysis Facilities. 
The two supplemental reports are (1) Practices of the Major Dialysis Corporations, and 
(2) Lessons Learned by the Major Dialysis Corporations and Implications for Medicare. 
LESSONS LEARNED BY THE CORPORATIONS 
Below are the lessons the corporations told us they have learned in using performance data. 
<  Look to medical directors to exert sustained leadership. 
<  Secure the commitment of attending physicians. 
<  Collect a broad set of measures and revisit their relevance regularly. 
<  Establish minimum performance standards and goals for all facilities to aim towards. 
<  Apply strict definitions to performance measures and check their accuracy regularly. 
<  Disseminate timely, comparative feedback of performance data. 
<  Stress quality improvement projects at the facility level. 
<  Use performance data as a guide to possible performance problems. 
OUR RECOMMENDATIONS TO MEDICARE 
Revise the Medicare Conditions for Coverage.  The revised Conditions should (1) require 
facility medical directors to exert leadership in quality improvement, and (2) require dialysis 
facilities to conduct their own quality improvement projects. 
Examine ways to foster the commitment of attending physicians to performance measures. 
CMS should (1) conduct educational forums that emphasize the importance of performance 
measures, (2) examine the possibility of physician-specific report cards, and (3) focus greater 
attention on the responsibilities of physicians. 
Develop more effective intervention strategies for facilities.  CMS should foster greater 
collaboration between its two oversight agents, the End-Stage Renal Disease Networks and the 
States, and address the confidentiality and liability concerns that impede such integrated efforts. 
Work with the corporations to share experiences and minimize burdens on dialysis 
facilities.  Both CMS and the dialysis corporations have similar concerns about improving care. 
More sharing of experiences could be helpful to both parties, and, most importantly, to patients. 
i
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  C O M M E N T S  
We received written comments on the draft report from the CMS, the Forum of End-
Stage Renal Disease Networks, Renal Physicians Association, National Renal 
Administrators Association, and the five corporate dialysis providers that were the focus 
of our inquiry.  Their comments were strongly supportive of the lessons we presented and 
of the thrust of the recommendations we made to CMS.  We include the full text of the 
comments in appendix C of 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).  On the basis of the comments, we 
made a number of clarifications and technical changes.  Below, we briefly summarize their 
comments and our responses to them. 
Medical Director Leadership.  CMS supported our recommendation that the Medicare 
Conditions for Coverage be revised to require medical directors to exert leadership in 
quality improvement.  The dialysis corporations and the other commenters also 
underscored the importance of such leadership, but to varying degrees raised concerns 
about how it might be defined in the Medicare Conditions.  They urged that leadership 
expectations be in accord with the real world in dialysis facilities.  Their comments 
reinforce the importance of CMS clearly establishing the medical directors authority and 
responsibility to provide leadership if it expects performance measures to be instrumental 
in improving care in dialysis facilities.  At the same time, the comments suggest the value 
of collaboration between the corporations and CMS in further defining the leadership role 
of medical directors. 
CMS and other respondents supported our recommendation that medical directors be 
given authority to conduct or initiate peer review of attending physicians.  But they were 
clearly wary of our recommendation that when patients are put at risk because of 
substandard medical care, the medical director should report the physician to an 
authoritative body, such as the facilitys governing board, the End-Stage Renal Disease 
Network, or the State medical board.  We suggest that this is a vital patient protection 
responsibility that must be part of the purview of the medical director and that CMS 
should address it as part of its efforts to foster quality dialysis care. 
Securing the Commitment of Attending Physicians to Performance Measures.  This 
is a vital matter having a significant bearing on the successful use of performance 
measures.  CMS expressed its readiness to consider the measures we called for.  Other 
respondents were supportive of convening educational forums.  But some raised concerns 
with the use of physician-specific reports (which are already being used by at least one 
End-Stage Renal Disease Network and by two dialysis corporations) and with the 
establishment of more explicit Federal standards or requirements concerning the 
performance of attending physicians.  We recognize that these are difficult issues, but 
suggest that they warrant careful examination as means of more fully engaging attending 
physicians in quality improvement efforts. 
ii
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i

COMMENTS ON THE DRAFT REPORT  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  ii

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

CORPORATE PRACTICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

LESSONS LEARNED BY THE CORPORATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Look to Medical Directors to Exert Sustained Leadership  . . . . . . . . . . . . . . . . . . . . . . . 4

Secure the Commitment of Attending Physicians  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Collect a Broad Set of Measures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Revisit the Relevance of the Measures Regularly  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Establish Minimum Performance Standards  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Develop Performance Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Apply Strict Definitions to Performance Measures  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Check the Accuracy of Performance Data Regularly . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

Minimize the Data Reporting Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Present Performance Data in Ways That Facilitate Comparative Assessment  . . . . . . . . .  7

Provide Timely Feedback of Performance Data to Dialysis Facilities . . . . . . . . . . . . . . . .  7

Stress Quality Improvement Projects at the Facility Level . . . . . . . . . . . . . . . . . . . . . . . .  7

Use Performance Data as a Guide  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Intervene with Facilities  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

RECOMMENDATIONS FOR MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Revise the Conditions for Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Foster the Commitment of Attending Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

Develop More Effective Intervention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Work with the Dialysis Corporations  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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

Appendix A: Glossary  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix B: Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

iii
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  I N T R O D U C T I O N  
PURPOSE 
To present lessons learned by the five largest dialysis corporations in using clinical 
performance measures to hold facilities accountable for the quality of care and to address 
the implications these lessons have for the Centers for Medicare & Medicaid Services, 
formerly the Health Care Financing Administration. 
BACKGROUND 
In our report, External Quality Review of Dialysis: A Call for Greater Accountability, we

urged the Centers for Medicare & Medicaid Services (CMS) 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 performance

measures.  Since then it has been active in carrying out this plan.

In this follow-up inquiry, we examine the practices of the five largest dialysis corporations

in using clinical performance measures to hold their own facilities accountable for the

quality of care.  We regard such an inquiry as important because:

(1) these corporations account for about 70 percent of all dialysis patients in the United

States, the vast majority of whom are Medicare beneficiaries, and represent over 2,000

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.1

This report is the main report in our series on Clinical Performance Measures for Dialysis

Facilities.  In addition to this report there are two supplemental reports.  The first

supplemental report, Practices of the Major Dialysis Corporations (OEI-01-99-00053),

describes the processes the corporations have to collect and use performance measures. 

The second supplemental report, Lessons Learned by the Major Dialysis Corporations

and Implications for Medicare (OEI-01-99-00054), presents 14 lessons the corporations

have learned in using performance measures and presents our recommendations to CMS

as it further develops its own system to use performance measures.  All three reports are

based on our review of corporate documents, interviews with corporate medical directors,

and site visits to several dialysis facilities.  The information contained in this report was

self-reported by the dialysis corporations.  We did not audit or validate the data the

corporations collect from their facilities.

We conducted this study in accordance with the Quality Standards for Inspections issued

by the Presidents Council on Integrity and Efficiency.

1
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052   Table 2.  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  no  no  yes  no  yes  no 
machine 
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  no  no  no  no  no  some 
are 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 
3
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  L E S S O N S  L E A R N E D  B Y  T H E  
C O R P O R A T I O N S  
Lesson 1.  Look to medical directors to exert sustained leadership. 
Corporations look to their medical 
The Role of the Facility Medical Directors and 
directors to exert leadership in two 
Attending Physicians 
key ways.  One is to lead by example. 
Since the medical directors typically 
Medical Directors. The Medicare Conditions for 
account for a majority of a facilitys  Coverage require each facility to have a physician 
patients, such leadership by example is  who serves as a medical director who is responsible 
of no small consequence.  The other  for planning, organizing, conducting, and directing 
the professional [end-stage renal disease] services. 
dimension is to ensure sustained 
Corporations contract with local physicians to serve 
attention in the facility to the 
in this capacity. For facilities that are not part of a 
improvement opportunities that  corporate chain, the facility owner and medical 
performance measures can offer.  The  director can be the same person. In addition to their 
corporations expect the medical  medical director duties, these physician directors 
have their own patients that can make up the 
directors to serve as the primary on-
majority of patients at a facility. It is not uncommon 
site agents to implement the corporate 
for a medical director to also be an attending 
initiatives concerning the collection 
physician at another facility regardless of the 
and use of measures.  ownership. 
The medical directors contracts spell  Attending Physicians. Dialysis facilities allow 
local physicians to send their patients to them for 
out their leadership responsibilities. 
treatment. Attending physicians may send patients 
These contracts include the 
to several facilities that may be owned by several 
responsibilities required by the 
different corporations or entities. The physicians are 
Medicare regulations as well as outline  not contractors or employees of the facility or the 
additional responsibilities required by  corporation, and their privileges can be revoked if 
the corporations.2  Among the  they do not adhere to the facilitys policies. 
contracts that we reviewed, we saw 
specifications that medical directors 
review their facilities performance measures monthly, attend regular training or meetings 
concerning quality improvement, and address attending physicians who are not performing 
adequately.  Two of the corporations even include in their contracts a provision indicating 
that a portion of the medical directors salary is contingent on how well their facilities 
fared on various clinical performance measures. 
The corporate officials disagreed about how fully they are able to hold facility medical 
directors accountable for exerting leadership.  Some stated that they had all the authority 
they needed through their contracts with facility medical directors.  For them, it was 
simply having the will to enforce their contracts.  Others drew attention to the limited 
leverage that the medical directors themselves have over the attending physicians who, 
unlike medical directors, do not have contractual obligations to the facility or the 
corporation and who often have patients at various facilities.3  The Medicare Conditions 
4
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  for Coverage do not make explicit that medical directors have the authority to take action 
concerning patients attended to by other physicians.4  Moreover, in competitive 
marketplaces, medical directors and attending physicians, if unhappy with a facility, can 
encourage their patients to move with them to another dialysis facility. 
Lesson 2.  Secure the commitment of attending physicians. 
For their own patients, the attending physicians determine the amount of dialysis, prescribe 
medications, and monitor the ongoing effects of dialysis treatment.  In performing these 
roles, the attending physicians have a considerable influence on the quality of care 
provided at dialysis facilities and can influence how well particular facilities fare on 
performance measures. 
Yet, corporate representatives indicate that these attending physicians are not necessarily 
drawn to facility-based performance measures.  With their patients in a number of different 
facilities, they may find any one facilitys measurements to be of little relevance to their 
own clinical performance.  And, as busy professionals, they may find that they have little 
time to devote to quality improvement efforts for which they receive no additional 
compensation. 
Still the corporations have devised ways to encourage attending physicians to participate 
in facility efforts to improve the quality of care being provided.  One approach they use is 
to establish clear standards that attending physicians must meet in order to send their 
patients to the facility.  Typically these standards are set forth in the facilitys bylaws. 
Another approach is to provide opportunities for physicians to attend seminars or 
conferences addressing performance measures and quality improvement.  Finally, to foster 
a stronger sense of individual physician accountability, two corporations provide 
physician-specific performance reports so that physicians can have data that are more 
relevant to their own practice. 
Lesson 3.  Collect a broad set of measures. 
Due to the complex nature of end-stage renal disease, it is important to monitor many 
different measures to obtain a better picture of the level of care.  Each of the corporations 
collects at least 14 different clinical performance measures.  The measures these 
corporations collect are familiar to most renal professionals and capture various clinical 
aspects of dialysis treatment.  They include measures that evaluate adequacy of dialysis 
treatment, anemia management, nutritional level, vascular access, bone disease, and 
hypertension 
Lesson 4.  Revisit the relevance of the measures regularly. 
The measures the corporations collect have changed over time in order to keep pace with 
scientific advances.  The corporations stated that if the measures were outdated (i.e., not 
clinically relevant), then physicians, nurses, and other renal professionals would be 
5
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052   time data analysts or statisticians at the central level that regularly monitor the data 
provided by their facilities and some corporations have built in automatic data edits into 
their computer software programs. 
Lesson 9.  Minimize the data reporting burden. 
Nurses and technicians are busy caring for patients and have little time left over for other 
activities.  To help reduce the workload, the corporations collect much of the facility-
specific data electronically, using several different approaches.  Some of the corporations 
have integrated their electronic data systems for quality management with their data 
systems for patient management that nurses and doctors rely upon to provide day-to-day 
patient care.  Three corporations obtain the results of lab tests directly from the 
laboratory, thereby eliminating the need for the facility to enter or send the data to a 
central location for analysis. 
Lesson 10.  Present the performance data in ways that facilitate comparative 
assessment. 
All the corporations facility-specific reports provide comparisons as a means to help 
gauge the level of quality at that facility.  The reports compare a facility to its own past 
performance and to its peers at the regional and national levels.  Corporate officials told us 
that comparisons are a big motivator for improvement.  They show at-a-glance where a 
facility stands among its peers. 
Lesson 11.  Provide timely feedback of performance data to dialysis facilities. 
If the data are 2 years old, or even a year old, physicians may tend to view them as 
something that shows a long-term trend that is irrelevant to the care they are providing 
today.  According to corporate leaders, the more recent the data, the more likely 
physicians and staff will take them seriously as a reflection of the care they are currently 
providing and make changes in their decision making process.  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. 
Lesson 12.  Stress quality improvement projects at the facility level. 
The corporations expect individual dialysis facilities to take the lead in conducting quality 
improvement projects.  They look to the facilities to identify problems and to develop and 
implement their own quality improvement projects.  Facilities are in the best position to 
know where they need improvement.  Furthermore, improvements can only occur if the 
individuals providing the care make changes in their processes.  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 
7
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  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. 
Lesson 13.  Use performance data as a guide to possible performance problems, 
not as definitive indicators. 
Corporations use performance measures cautiously, as signals of possible problems.  Prior 
to intervening, the corporations seek to verify the concern.  They may examine the results 
of recent patient satisfaction surveys, complaints, results of any State surveys, adverse 
event reports, and the current demographics of the patient population.  Some corporations 
wait until a definite pattern appears over several months before they will intervene. 
Corporate representatives emphasized that performance measures used in isolation can 
lead to false conclusions on both sides.  A facility that fails to meet minimum performance 
standards may in fact be providing high quality care.  Similarly a facility that exceeds 
performance goals may be providing inadequate care. 
Lesson 14.  Intervene with facilities having performance problems in ways likely 
to motivate change. 
The corporations begin their interventions with targeted training programs.  Often the 
training occurs on site so that corporate officials can review first-hand the practices of the 
facility.  Many of the corporate officials believed that training would not only help the 
facility fix its current problem, but also help address problems in the future.  If training 
fails, the next level of response is peer review.  Corporate officials indicated to us that 
physicians and nurses are more receptive to advice from their regional peers than from a 
person in an executive position.  It was rare that they had to resort to punitive actions 
such as firing facility staff, terminating contracts with facility medical directors, or 
revoking attending physician privileges. 
8
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  R E C O M M E N D A T I O N S  
Similar to the corporations, CMS has systems in place to collect and disseminate facility-
specific performance measures and their national clinical performance measures have 
shown considerable improvement in the quality of care.  The experiences of the 
corporations is of considerable relevance to CMS as it seeks to strengthen its own use of 
facility-specific performance measures.  Drawing on the lessons the corporations have 
learned, we make several recommendations to CMS on how it can improve its efforts. 
Revise the Medicare Conditions for Coverage for dialysis facilities. 
Require facility medical directors to exert leadership in quality improvement. 
The current Conditions for Coverage (Medicare regulations for dialysis facilities) do not 
explicitly require the medical director to take the lead in quality improvement.  The 
corporations have learned that, if performance measures are to be used effectively at the 
facility level, someone at the facility must take the lead to ensure that the nurses, attending 
physicians, and the technicians are all attuned to quality improvements.  The medical 
director, who typically serves as a member of the facilitys governing body, is in the best 
position to fulfill this leadership role.  Without medical directors being fully committed to 
and engaged with quality improvement activities, important opportunities for enhancing 
patient care are likely to be missed. 
CMS should also address in the Conditions what medical directors are expected to do 
when a quality problem is attributable to an attending physician who is not performing 
adequately.  It should make clear that: (1) medical directors have the authority to conduct 
or initiate peer review and to address performance problems through directed education, 
and (2) for more serious situations, the medical directors responsibility to report a 
physician to an authoritative body, such as the End-Stage Renal Disease Network and/or 
the State Medical Board.5 
Require dialysis facilities to conduct their own quality improvement projects. 
CMS can give added impetus to such facility-based efforts by enacting a Medicare 
requirement that facilities undertake quality improvement efforts.6  The requirement need 
not stipulate the type of efforts, but should call upon the facilities to draw on performance 
measures, as well as other sources of information, to improve the quality of care provided. 
This expectation should apply even for facilities that have comparatively high performance 
scores.  All facilities, it seems reasonable to assume, can do better.  Such a mandate need 
not preclude national or regional quality improvement projects; but the corporate 
experience suggests that they should be of lesser significance than those that are facility 
specific. 
9
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  Examine ways to foster the commitment of attending physicians to 
performance measures. 
Our review suggests three ways CMS could foster the commitment of attending 
physicians.  First, CMS, through its facility oversight agents, the End-Stage Renal Disease 
Networks, should provide educational forums for nephrologists that clearly convey the 
value of performance measures and their relevance to the everyday care of the patient.  A 
second direction is to generate physician-specific report cards.  One Network, as we noted 
in a prior report, has been doing this since 1997.7  Similarly, two of the dialysis 
corporations provide physician-specific report cards so that physicians can see how their 
performance compares with their peers.  A third direction is to more fully address the 
expectations of attending physicians to contribute to and be responsive to quality 
improvement efforts.  CMS may want to consider revising the Conditions for Coverage to 
require facilities to have a credentialing process for attending physicians similar to the 
regulations in place for hospitals.8 
Develop more effective intervention strategies for dialysis facilities. 
CMS relies on two organizations, each with its own expertise and authorities, to oversee 
dialysis facilities: the End-Stage Renal Disease Networks and the State survey agencies.9 
The Networks have clinical expertise and the States have regulatory authority to enforce 
the Medicare Conditions for Coverage.  CMS provides facility-specific data to each that 
can help them identify poorly performing facilities in need of intervention.  Even though 
these entities complement one another, we found in our June 2000 report on dialysis 
facilities that the States and the Networks rarely communicate.  This breakdown can lead 
to ineffective interventions and limits the available options to address poorly performing 
facilities.10  In order for the States and the Networks to work together more effectively, 
CMS will first need to address issues around confidentiality and liability, which have 
inhibited collaboration in the past. 
CMS may want to consider expanding the sanction options for dialysis facilities that fail to 
comply with the Conditions.  Currently, Medicare has very few options, short of 
terminating the facility from the Medicare program, to sanction dialysis facilities.  It may 
want to consider seeking the authority to deny Medicare payments to new admissions at 
facilities that fail to meet Medicare Conditions.  A similar process is already in place for 
nursing homes.11 
Work with corporations to share experiences and minimize burden on 
dialysis facilities. 
CMS and its agents, the States and the Networks, have little interaction with the dialysis 
corporations.  CMS focus has been on the licensed facilities, not the parent corporations. 
Yet, the parent corporations, like CMS, are also engaged in the external quality oversight 
of dialysis facilities.  From different vantage points, the two have many of the same 
10
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  concerns.  Our review suggests that it could be beneficial for both parties, and most 
importantly for the patients, for more collaboration and sharing to take place.  CMS 
should consider sponsoring meetings and conferences for itself and the corporations to 
share information as well as find ways to share data and information on a routine basis. 
One concrete step that CMS should take is to share its facility-specific data reports 
directly with the relevant corporations. 
11
Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  APPENDIX A 
Glossary of Clinical Performance Measures 
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. 
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Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  APPENDIX B 
Endnotes 
1.  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]. 
2. 42 C.F.R. Sec. 405, Subpart U. 
3.  CMS (Medicare) pays attending nephrologists for routine dialysis care through a monthly 
capitation payment. 
4.  CMS made this clear in a 1998 letter to an ESRD Network: Significantly, the end-stage renal 
disease regulations do not explicitly empower a physician-director with the authority to take 
independent action with respect to patients attended by other physicians.  Correspondence to 
Glenda Harbert, Executive Director of Network 14, from Kay Hall, Project Officer, Division of 
Clinical Standards and Quality, Health Care Financing Administration, on November 9, 1998. 
5.  The End-Stage Renal Disease Networks, established in 1976, are CMS main contractors for 
monitoring 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. 
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Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052  APPENDIX B 
6.  The minimum standards for dialysis facilities issued by the Texas Department of Health include 
one calling for facilities to conduct their own internal quality improvement efforts. 
7.  Department of Health and Human Services, Office of Inspector General, External Quality 
Review of Dialysis Facilities: Two Promising Approaches, OEI-01-99-00051, June 2000. 
8.  42 C.F.R. Sec. 482.22. 
9.  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. 
10.  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. 
11.  42 C.F.R. Sec. 488.408 (d)(1)(i). 
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Dialysis: Building on the Experiences of the Corporations   OEI-01-99-00052