August 27, 2007
National Quality Forum
601 13th Street NW
Suite 500 North
Washington, DC 20005
On behalf of the American Nephrology Nurses Association (ANNA), I am writing to express our appreciation to you for inviting us to comment on the National Voluntary Consensus Standards for End Stage Renal Disease (ESRD) Care, 2007. As an organization dedicated to providing the highest quality care for patients suffering from kidney disease, we are pleased that the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) have initiated this project.
ANNA is a professional nursing organization of more than 12,000 registered nurses practicing in nephrology. ANNA members are intimately involved in the supervision and delivery of care to adults and children with kidney disease. Our members work in a variety of setting including dialysis facilities, transplant centers, Chronic Kidney Disease (CKD) clinics, acute care, ambulatory clinics and long-term care. ANNAs purpose is to advance nephrology nurse practice and positively influence outcomes for patients with kidney disease through advocacy, scholarship and excellence.
ANNA endorses all the measures outlined in the draft document. Our Association does have several concerns regarding the process that we are documenting here.
- Variations in facility resources and patient demographics will make measure achievement difficult for many facilities and enhances the probability of cherry picking patients. It would be advisable to develop a method for systematically measuring facility improvements over time (beginning of fiscal year to the close of the same year then repeat the process the next year). Quality measures should aim to improve performance (serve to enhance or drive performance) rather than simply denote failure to achieve.
- Exemplary performance measures are based on a high level of data integrity. Many of these measures will require considerable time (resources) to manually abstract the data from electronic or paper records. If nurses are given the responsibility of collection, then there is concern that this will take away from their patient care responsibilities and patients may ultimately suffer. Presently, the tools that could be utilized to track, study and manage trends in patient care are either costly, not proven effective or inadequate. A universal system for tracking ESRD performance data needs to be developed to ensure data integrity and enhance abstraction feasibility.
- A few of the measures (e.g., measurement of serum calcium and phosphorus) are already an expectation and thus most facilities will achieve 100% compliance. This process metric is not in its current format developed as such to drive practice improvement.
- There is a real concern for confidentiality with the measures that require administration surveys. Even though there is no disclosure of patient identifiers, there is the potential to discern respondents based upon responses. Many of the questions relay personal information relative to their perception of disease and its treatment. In-center or mail out sampling has the potential to divulge information that can inflict personal harm. This method of data retrieval provides very limited safeguards and no guarantee of confidentiality. Nurses believe that a patient's right to privacy is paramount to their overall care.
Again, thank you for the opportunity to participate in the review of the Consensus Standards for ESRD Care. If you have any questions, or if we can be of assistance to you or your staff on kidney disease, nursing or related matters, please do not hesitate to contact me.
Sandy Bodin, MA, RN, CNN
American Nephrology Nurses Association
cc: Karen Pace, PhD, RN, Senior Program Director