Journal Departments

Controversies in Nephrology Nursing

What is Better for Patients and Staff – Independent
Units or National Dialysis Chains?
Christy Price Rabetoy, Department Editor

Independent Ownership of Dialysis Units is Better for Patients and Nurses
Susan Blalock, MS, RN, CNN
Facility Administrator
Dialysis Treatment Center of North County
St. Louis, MO
Member, St. Louis Chapter of ANNA

I enjoy working for an independent facility, because it has the benefit of the freedom from corporate restraints and political bureaucracy, and moreover the unit encourages independent functioning and thought with a unified team approach to improving patient outcomes. I will further explain my perceptions as related to patients and nephrology nurses.

Freedom From Corporate Restraints

Recently, the state surveyor visited, and corrections were advised. Policy and procedure changes were necessary, and initiation of these new policies was an expectation. Some staff retraining was required. There was a need for purchases to satisfy certain conditions of correction. As an independent facility, there is no corporate process for making changes in the facility. I have the autonomy in my unit to make the corrections and changes as needed with approval of the Medical Director, because we work together as a team to provide the best care for the patients.
The concern for finances is always a consideration in any dialysis facility, whether an independent unit or giant corporation. The goal is effective care for patients in a cost-efficient manner by using all available resources. Most chain facilities have strict budgetary restraints to comply with in justifying purchases. In an independent unit, we are able to follow a different route with similar results. This includes the lack of red tape needed to purchase certain items that would not be in the established budget. This is the freedom that large corporations do not allow easily. We are not at the mercy of shareholders to make a profit.

Independent Functioning of Nurses

The focus of our unit is patient safety and satisfaction. We accept only the best from our staff. When you focus on the patient as the main customer and think outside the box, you challenge the staff to create new possibilities and feel free to make suggestions. We all know the old cliché “if the patient is not in the chair, the unit does not make money.”

Keeping our patients out of the hospital is in their best interest. Educating the patients on the adverse outcomes of shortened and skipped treatments will decrease hospital days and improve quality of life. This is a challenge for all of us in any facility, requiring many hours of patient education and repetition of that education. As an independent dialysis provider we have the opportunity to permit nurse educator time, a role that has been eliminated in many facilities.

Every facility has is a culture of its own. Patients spend a lot of their time with each other, and they become concerned when a fellow patient is ill. If any staff member does not act appropriately in conveying information about other patients, the patients may become uneasy about their care. Supervising unlicensed assistive personnel regarding appropriate information is always a challenge, but nephrology nurses must make certain that the unit environment is always one of empathy and caring. I feel this atmosphere is more easily fostered in a dialysis unit where a sense of ownership exists, that is, we feel the unit is truly “our unit!”

Local Team Approach Improves Outcomes

Disease management has become the standard of care of our patients. Focusing on the numerous problems associated with renal failure will assist in the overall improvement in patient outcomes. By having a vascular access manager, you empower this nurse to focus on the goal to have fistulas placed prior to initiation of dialysis ideally, but as soon as possible after the initiation of dialysis. The nurse can help coordinate the necessary referrals, assist patients with appointments, monitor follow-up care, and instruct patients on the proper exercises to promote development of an arteriovenous fistula. The vascular access manager also has an important role in teaching the unit staff on the correct access cannulation techniques and appropriate monitoring. By solidifying staff commitment, everyone feels important and included in influencing outcomes.

The quality improvement leader is another unit role that supports the team goal of working together to assess the needs of the clients and formulating a plan to reach that goal. All staff are encouraged to share information when a problem exists, fill out incident reports, and make problems or mistakes a learning experience, not a reprimand. When an opportunity presents itself for improvement, the quality improvement leader has the authority to initiate the process.

Similarly, an anemia manager, bone manager, and diabetic educator can be empowered and accountable in the success of patients. In an independent unit, an organizational and operational chart can be devised without seeking permission from some national office. All control is at the local level.

Admittedly, there are drawbacks to any situation, none being perfect. The independent unit cannot offer as many benefits or perks to the staff. On the other hand, we can buy them lunch, give them a bonus at Christmas, or organize a summer gathering as budget permits. As stated earlier, we can create an environment that enhances the camaraderie and pride of “our unit.”

I feel strongly about independent facilities and enjoy working at one. I have seen many changes in nephrology in my career, the most significant change being that when I started, 90% of dialysis facilities were independent while today 70% of the market is owned by two major national chains. Not all change is for the best.

Large Dialysis Organizations (LDO’s) Are Really Concerned About Patient Care and Staff Well Being
Norma Gomez, MBA, RN, CNN
Director of Education
DaVita, Inc.
Member, South Florida Flamingo Chapter of ANNA
ANNA National Treasurer

Throughout my career as a nephrology nurse, I have had the opportunity to work for some great patient- oriented companies. I have worked for not-for-profit, for-profit, independents, physician owned, county run, and of course several LDO’s. The question always comes up from some of my colleagues, “how can you work for an LDO, aren’t they just about money?” Currently there is more disparity of care between our different patient populations than the disparity between the companies that provide that care. One of the companies I worked for focused company goals and strategies on three distinct areas: patient care, employee care, and business care. I would like to address the subject of LDO’s based on patient care and employee care.

Patient Care

Patient education. I believe that patients receiving care at an LDO have more resources available to them. Most of the LDO’s have patient education programs, including web sites that discuss various aspects of chronic kidney disease, modality selection, renal diet recipes, emergency preparedness, and research. This information is not only focused on the patient but also has a family and community focus. Several of the LDO’s have pre-ESRD education programs. These programs are available to nephrologists and primary care providers to help educate the patient and their family as they move through the stages of kidney disease. Currently, there is no funding for these programs from Medicare.

Insurance assistance. The patients are assisted through the complicated and confusing process of “insurance coverage” by individuals trained specifically in that area. Most LDO’s have some form of financial assistance program in place to help patients who cannot afford the astronomic costs of renal replacement therapies and all that goes with it. With financial resources getting tighter and tighter, we are seeing small rural dialysis facilities close. I have read at least two articles recently about patients having to drive over 2 hours to get to a “big city” facility because their small town facility had been closed. There are some LDO facilities in rural areas being kept open even though they are not profitable. There may be various reasons that this is occurring, but bottom line is that the patients still have access to care.

Catastrophic assistance. As Mother Nature continues to be on a rampage (hurricanes, floods, tsunami’s) we have seen more and more people’s lives devastated. Several LDO’s have catastrophic funds available to patients affected by natural and/or personal disasters. These funds helped many of the patients last year in the aftermath of four major hurricanes hitting the coasts of Florida.

Representation. LDO’s encourage patient participation in AAKP, NKF and legislative activities. They have supported ANNA’s ESRD Education week and have encouraged patients to be active in the legislative process. Most LDO’s have a facility patient services committee. These committees work with the facility administration to improve services in each clinic.

Employee Care

Training. Employees hired into a LDO receive standardized training. Clinical staff are taught all aspects of renal disease and most complete competency testing. There are also training programs for the support services staff. Several years ago I was auditing an independent provider that had some problems with the state agency. The director of nursing had just been hired by the physician and was not provided with any training or resources. I gave her the resource information regarding ANNA’s Nephrology Nursing Standards of Practice and Guidelines for Care, Network contact information, and the State Renal Administrators Association information. She was amazed at the available resources and implemented several changes before we completed the audit. This situation would not occur in an LDO with all the corporate resources available to new staff and new facilities.

Resources for employees. Most of the LDO’s have some type of tuition reimbursement program. One LDO has a scholarship program for patient care technicians to continue working and complete nursing school. With the cost of health care rising, the LDO’s are able to offer more benefits to their employees at lower costs because of their size.

Career advancement. Career opportunities in LDO’s are unlimited. Training is available for each position. Employees can transfer from one area of the country to another without losing seniority or benefits.

Current data regarding patient outcomes has indicated that the top performing facilities are those associated with LDO’s. Most LDO’s have a quality manager or outcomes manager position to follow up on those patients not meeting the K/DOQI standards. The patient care planning committee reviews individual patients, and changes are made to prescriptions to improve outcomes. I outlined just a few of the positives that both employees and patients receive being associated with an LDO. So, how can I work for an LDO? You tell me!

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.