How-To Choose the Right Dialysis Facility

What should you look for in a dialysis facility?…SAFETY FIRST!

What exactly does that mean? Obviously we all want to be safe and receive good quality care. But the reality we must acknowledge is receiving good quality care does not always happen.

Why you may ask? Well, many reasons, none of which are good or acceptable. Fact: Putting profits over patients leads to poor outcomes. Inadequate staffing, poorly maintained equipment, lack of emergency equipment/supplies, poorly trained staff and/or inexperienced staff are examples of at-risk or reckless management.

In the spirit of keeping yourself, or a loved one, safe and in optimum health, self-advocacy is your best assurance. If your medical condition does not allow for you to advocate for yourself, it is very important that you ask a loved one, or you can hire a registered nurse with dialysis experience to advocate for you.

The following checklist provides suggestions that a patient/patient’s family, or advocate should look for when choosing a dialysis facility. Many times a specific facility is recommended, yet you should visit and see if that facility is a fit for you. Perhaps you think it is a great facility because it is close to your home. Although this can be an important consideration when choosing a dialysis unit, it should not be your primary reason. There are other facilities that you may want to consider, should you not find what meets your needs and standards at the first suggested clinic.

Patients

Make sure you visit while patients are on dialysis!

Nothing says more than seeing and hearing from actual patients who have already been dialyzing at the dialysis unit. Ask the Director of Nurses to arrange for you to meet with some of their current patients while you are at the facility for a tour. Allowing for the privacy between you and the patient may assure more candid responses.

Observe:

Is the staff friendly to the patients?
How familiar does the staff seem with their patients?
Does the staff immediately respond to machine alarms?
Does the staff mute alarms and walk away without attending to what caused the alarm?

Some questions you may want to ask the patients include:

Are you happy?…ASK THEM!
Do you feel well taken care of? Do you feel safe?
Do you feel adequately monitored?
Have you ever been dissatisfied with treatment, the facility, or the staff?
If so, what was it and how did the dialysis unit management or staff resolve the problem(s) and/or concern(s)?
What are your opinions about the dialysis facility?
Are you ever without staff members in the immediate dialysis treatment area (even just for a few minutes)? If yes, when? Why?
How often does the dialysis facility have patient care conferences with nursing, physician, dietician, and social worker together? Are the patient and/or their family/advocate involved in these conferences?
Were you offered kidney transplantation?
Does the patient you are talking to know their URR*
Does the patient you are talking to know their Kt/V?**

NOTE: You may want to also ask the patients some of the same questions you asked the
staff to see if the answers and perceptions are the same.

Is there a method to measure patient satisfaction in the unit?
Some dialysis units survey patients to find out if they are satisfied with their care. Ask the person who conducts your tour if the results are shared with patients. Will they share a copy of the results with you?

*URR = Urea reduction rate, or the amount of reduction in the urea in the blood as a result of the dialysis treatment. It is one measure of how effectively a dialysis treatment removed waste products from the body and is expressed as a percentage.
A minimum of 65% + is expected.

** Kt/V:
K = the dialyzer clearance of urea; t = dialysis time; V= volume of distribution of urea, approx. equal to patient’s
total body water. The National Kidney Foundation target for Kt/V is 1.3

Safety

Don’t be afraid to ask questions and look around…your safety should be their #1 priority!

Ask & Observe:

Does the facility provide blankets, or sheets? If no, can you bring your own?
Do you see blankets and sheets on patients and CANNOT SEE their access sites as they are under the covers? NOTE: This is one of the most important things to observe while visiting a dialysis unit! Venous Needle Dislodgement (VND) is one of the biggest safety risks of hemodialysis.
How quickly does management expect the staff to respond to a machine alarm?
Are patients ever left alone in the treatment area?
What is the patient to patient care technician (PCT) ratio?
What is the patient to R.N. ratio?
Are all staff wearing gloves and face guards when connecting or disconnecting patients from the dialysis machine?
Does the unit have an isolation room?
Does the dialysis unit provide venous needle dislodgement (VND) training to its staff? If yes, what does this entail? How often are the trainings provided?
Does the facility use Redsense alarms*? If yes, for which patients? Do you have the right to request Redsense alarm be used for your treatments?

* Redsense Venous Needle Dislodgement (VND) alarm is a blood loss detection device with a sensor patch and an alarm unit. This is an early warning device to alert dialysis staff of the serious complication of inadvertent blood loss.

Staff

You need to know that they will work to help you function at the highest level of health possible!

Ask & Observe:

Does the staff seem to have a communicative relationship with the patients?
Listen to how the staff talks to and approaches the patients? Is this how you would want to be spoken to? Is the staff addressing the patients respectfully?
See if you can talk to the staff. What do they like about working there? Ask them how long they worked there. Does the staff have complaints about the dialysis unit?
What is the patient-to-RN ratio?
PCT-to-RN ratio?
PCT-to-patient ratio?
Will your own nephrologist see you while on dialysis? If yes, how often?
How is the staff trained? RN ? PCT? …are they certified? Who provides the certification?
Is continuing in-service education provided by the unit to its staff? If yes, how often and by whom?
How does the dialysis unit handle staff sick calls?
What are the qualifications of temporary staff?
What are the observable dynamics between staff members?
Is there tension? Trust?
Will your treatment times be scheduled around your work schedule? How flexible is the treatment schedule?
Will the facility staff make arrangements for you if you want to travel to another city, state or country?

Patient Education, Treatment, & Support

After all, this is about YOU getting the best care!

Ask:

Is kidney and dialysis information available should you want it?
Is time allowed for the registered nurse, social worker and dietician to meet with you and answer your questions?
Does the facility offer a chronic kidney disease (CKD) education program? If you have not yet started dialysis, receiving education early will help you become a more proactive and informed participant in your healthcare.
What different dialysis treatment modalities are offered (examples: home hemodialysis, peritoneal dialysis, self care)?
Is kidney transplantation offered?
How does the dialysis facility assist you in referral for transplant work-up?
Does the facility have patient group meetings?
Is there a support group run by the social worker? Run by patients?
Are their goals and objective for the group or is it a complaint session?
Is information provided and supported from the Network?

Reuse & Equipment

There is no excuse for poorly maintained equipment!

Ask & Observe:

Does the unit reuse dialyzers? If so, what are their policies and procedures for assuring that you get ONLY YOUR OWN DIALYZER.
What safety measures are in place to assure dialyzers are not mixed between patients?
What specific emergency equipment and medication is available at the dialysis unit? Where is the emergency equipment located?
Is the emergency equipment close to the patient care area?
How often is the emergency equipment checked?
Is staff trained to use the emergency equipment? How often is this reviewed for the staff?
Are there oxygen tanks at the dialysis unit? How often are the checked?

Environment

Ask & Observe:

Is the dialysis unit clean? Do you see blood spills/splatter in the facility?
Does the facility provide blankets, or sheets? If no, can you bring your own?
Do you see blankets & sheets on patients and CANNOT SEE their access sites?
Are all staff wearing gloves and face guards when connecting or disconnecting patients from the machine?
Does the unit have an isolation room?
Does the unit accept hepatitis and HIV positive patients?

Vascular Access

How a person’s blood is accessed to enable hemodialysis to be performed

Ask & Observe:

What percentage of patients have AV fistulas? AV fistulas are the preferred access for hemodialysis.
Different types of vascular access include: arteriovenous fistula (http://www.fistulafirst.org/ ), arteriovenous graft, and venous catheter.
Does the facility use Redsense alarms*? http://www.redsensemedical.com

* Redsense Venous Needle Dislodgement (VND) alarm is a blood loss detection device
with a sensor patch and an alarm unit. This is an early warning device to alert dialysis
staff of the serious complication of inadvertent blood loss.

Emergencies and Disasters

They happen! Is your facility prepared?

Ask:

What are the emergency plans in case of a disaster?
What preparations have been made in the event of a natural disaster to be dialyzed?
Are the evacuation plans explained as a matter of routine? How often do they review these with their patients?
What is the backup in case of a medical emergency?
How often does the facility call for emergency backup?
Do they review clamp and cut procedures with both staff and patients?

Observe:

Are clamps and scissors taped to each station in case of an emergency?

General Questions

Ask:

Who is the medical director of the dialysis unit?
What government agency surveys the dialysis unit? Get the specific name and contact information. Also, ask to see the surveys.
Who owns the dialysis unit?
Is there continuity of care? If you are hospitalized, does the staff at the dialysis unit communicate with the hospital about your treatments?
If hospitalized, who would do your inpatient dialysis treatments?
Is there a person who notifies the unit when to expect your return to the unit?
If you or your family members are not fluent in English, ask if there is a translator available.
Was the facility management or staff defensive about the questions you asked?
What about the information you requested?

Once You’ve Asked Your Questions…

Request to read the Department of Public Health survey reports (CDPH in California) for the last three surveys….. and READ THEM! Be certain to include complaint investigation reports. Ask questions! You can also call the Department of Health District office with questions about the reports or call PJ West & Associates office and we will be happy to assist you with your state specific information.

knowledgeispower_image6 Look at the following website: www.medicare.gov/dialysis/home.asp. Where does the dialysis unit you are considering rank when compared to other local units?

A learning culture and an environment of transparency is one of the best ways to assure your safety. This is a culture that is doing its best to produce the best possible outcomes. It is a culture that is willing to see risk in individuals as well as within their organization. By doing so, it should prevent mistakes from being repeated. A Just Culture allows staff to admit to their mistakes and to identify the differences between human error, at-risk behavior and reckless behavior.

What is the dialysis units’ philosophy about transparency? Are they open and forthcoming about what they can and cannot commit to? Do they create a punitive environment wherein it is not safe for staff to come forward and report either a mistake or near miss? Or do they create a blame-free environment where NO ONE is held accountable for anything? (yikes!)

I suggest that you look for a dialysis unit where knowledge and skill is supported, which increases the opportunities for success. Success on the part of the staff means that patients are safe. Safety precautions need to be in place to prevent human error; if missed, additional checks should be in place to catch an error before it reaches a patient, and potentially result in a bad outcome. This process should be the goal of your pre- dialysis visit when choosing a facility. It should also be revisited and these same questions asked a few times a year or if you observe changes within the facility where you receive your treatments.

Resource Corner

American Association of Kidney Patients: www.aakp.org
Arteriovenous Fistula First: http://www.fistulafirst.org/
Dialysis Facility Compare: www.medicare.gov/dialysis/home.asp
National Kidney Foundation: www.kidney.org
PJ West & Associates, Inc.: www.pjwa.com; (818) 707-0051
ProPublica: www.propublica.org
Redsense Alarms: http://www.redsensemedical.com

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