Identifying best practices in dialysis care: results of cognitive interviews and a national survey of dialysis providers.
OBJECTIVE
Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes.


METHODS
This multidisciplinary study identified candidate best practices in dialysis through a staged process, including systematic review, cognitive interviews, and a national "virtual focus group" of dialysis providers. The resulting candidate practices were rank-ordered by perceived importance as determined by mean RAND Appropriateness Scores from a national survey of nephrologists, nurses, and opinion leaders.


RESULTS
A total of 155 candidate best practices were identified. Among these, respondents believed dialysis outcomes are most strongly related to 1) characteristics of multidisciplinary care conferences, 2) technician proficiency in protecting vascular access, 3) training of nurses to provide education in fluid management, vascular access, and nutrition, 4) use of random and blinded audits of staff performance, and 5) communication and teamwork among staff. In contrast, there was wide disagreement about the importance of facility-based health maintenance practices, optimal staffing ratios, frequency of dialysis-based physician visits, and optimal frequency of multidisciplinary care.


CONCLUSIONS
This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.
Desai
Amar A
AA
Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
Bolus
Roger
R
Nissenson
Allen
A
Bolus
Sally
S
Solomon
Matthew D
MD
Khawar
Osman
O
Gitlin
Matthew
M
Talley
Jennifer
J
Spiegel
Brennan M R
BM
D000328:Adult; D001291:Attitude of Health Personnel; D019985:Benchmarking; D002983:Clinical Competence / Q000592:standards; D003071:Cognition; D004506:Education, Nursing / Q000592:standards; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006268:Health Facilities / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000592:standards; D006297:Health Services Accessibility / Q000592:standards; D006302:Health Services Research; D006801:Humans; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D008297:Male; D008485:Medical Audit / Q000592:standards; D008875:Middle Aged; D024802:Nurse's Role; D010348:Patient Care Team / Q000592:standards; D010465:Perception; D010561:Personnel Staffing and Scheduling / Q000592:standards; D016730:Program Development; D006435:Renal Dialysis / Q000592:standards*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014481:United States