The CMO Initiative: Working toward changes in nephrology practice

Build it and they will come.

In November 2012 the three of us invited dialysis provider chief medical officers (CMOs) to attend a two-day workshop in Chicago, set for March 2013. The purpose was to discuss and to advance the implementation of specific interventions likely to improve care in advanced chronic kidney disease and kidney failure. This would be a low budget affair: everyone would pay his or her own way, and no one would receive an honorarium. The only requirements were that each participating organization must be willing to share its practices openly, and that every participant must come ready to engage in open discussions. We knew that DCI, DaVita and Renal Ventures would be there; we just didn’t know if anyone else would show up.

When the day arrived last March, so did the CMOs from all 14 invited providers, responsible for the care of more than 85% of dialysis patients in the United States, and accompanied by 60 close operational associates. We met as peers, and each CMO had equal opportunity to address the group, regardless of size of the organization he or she represented. At the end of the second day, we broke into small groups, each comprising representatives from each provider, and formulated topical consensus recommendations. The topics discussed included CKD education; rehospitalizations; extracellular fluid volume management; vascular access; peritoneal dialysis; first 120 days of dialysis, and nutrition.

Following the workshop each group developed a summary document that could potentially be used as a white paper to share within dialysis organizations and more widely within the kidney care community so that physicians and other caregivers could see the recommendations of the workshop groups. To date several of the white papers have been published and the others are being finalized.

The COOs and other operationals from the various providers talk monthly about issues they face in their dialysis facilities: staffing, infection control, access complications, etc. In addition, the CMO group was and remains very concerned about the current focus of the Centers for Medicare and Medicaid Services’ Quality Incentive Program program, an important component of the ESRD Prospective Payment System. Aligning the QIP metrics with the areas of greatest clinical impact for patients would be key to driving innovative quality initiatives more rapidly. A paper authored by several of the CMOs along with other experts in this area will be published in the Clinical Journal of the American Society of Nephrology later this year to provide guidance in this area.

Finally, at a meeting of the CMO group held last November in Atlanta during the American Society of Nephrology meeting, there was a unanimous decision among the CMOs, building on the initiatives from the previous year, to convene a second annual meeting. This will be held in Baltimore from March 6-8. Attendance will be limited to CMOs of the invited providers (there has been consolidation of some providers since the original meeting) and the corporate operational staff. Also in attendance will be invited expert faculty for specific issues being discussed.

An overview of the agenda consists of the following topics:

Going beyond traditional quality indicators
Changing mortality, hospitalizations, and sudden death
Debate over changing traditional dialysate
Infection control
Acute kidney injury
Unique staffing patterns
Understanding the Kidney Care Partners blueprint
Transitions of care models
Effectively managing extracellular fluid volume
Standardizing reporting

Among the invited speakers are Allan Collins, Chris McIntyre, Francesca Tentori, Edward Siew, and Paul Kimmel.

It is anticipated that consensus among the providers will be gained in many of these categories of care. It then becomes the option of each provider, and others through dissemination of the meeting’s results, as to how to implement change within the environs of their infrastructure.

This is a unique collaboration, solely for the purpose of improving the welfare of patients. -by Tom Parker III, MD; Doug Johnson, MD; Allen Nissenson, MD

To read position papers developed by the CMO group during 2013-2014, go to nephrologycom.wpengine.com/cmo.