(continued on page S4)

In-center hemodialysis is a uniquehealthcare setting. Nowhere else do we see the same patients—some-times for years—on an outpatientbasis, three times a week. In fact,the most analogous scenario is nurs-ing home or other institutional care.

The chronicity of our patients canmake it easier to see when some-thing is wrong and to correct it andimprove outcomes. However, con-stant contact with the same patientsover time also creates the potentialfor conflict when differences of opin-ion arise, as they inevitably will.

The kidney community has paid alot of attention recently to quantifyingand coping with conflict. The ESRDNetworks, in particular, released alengthy and detailed report of theirDialysis Patient-Provider Conflict (DPC)consensus project, containing infor-mation about factors that contributeto conflict, data, and action options.1

As Benjamin Franklin noted, “an ounceof prevention is worth a pound ofcure.” Examining our paradigm fordialysis care may offer clues to helpus avoid conflict and its ill effects onboth staff and patients.

The Disruption of Conflict“Conflict” is defined by Webster’sNew World Dictionary as: “to fight,battle, contend; to be antagonistic,incompatible, or contradictory; be inopposition; clash.” It is no surprise,then, that for staff, conflict with

patients can be stressful and maycontribute to increased turnover.It’s difficult for anyone to come to workknowing they will encounter someonewith whom they don’t get along.

For patients, the costs of conflict maybe higher—even life or death. LifeOptions research found that patientswho had to “assertively self-advocate”scored significantly lower on themental component summary (MCS)scale of the Medical Outcomes StudyShort Form–12.2 Lower MCS scorespredict higher morbidity and mortality:3avoiding conflict up front is betterthan coping with it after the fact.

Conflict can compromise patients’lives in another way: an ESRDNetwork survey conducted in 2002revealed that 458 patients (0.2% ofthe population) were involuntarilydischarged from a dialysis clinic(primarily for “noncompliance”)—anddeaths have occurred when patientswere not able to find a new clinic.4

Walk a Mile in Patients’ShoesESRD Network 2 developed sensitiv-ity training to help dialysis staff—especially technicians, who are frontline to patient care—betterunderstand patients’ experience oflife on dialysis in order to preventconflict.5 Focusing on patients’ fear,vulnerability, and day-to-day stressand anxiety can help staff to

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In Control is supported by Amgen Inc.

Preventing Conflict in Dialysis:The Value of Customer Service

VOL. 2 | NO. 4

DECEMBER 2005

and published in cooperation with

A Medical Education Institute/Life Options Publication

How to Use In Control

Each issue of In Controloffers background, tips, andpatient education material onone issue that is important to living well with kidney disease. The 2-in-1 format of In Control is designed tomake it easy to find the infor-mation and share it with your patients.

For you, there are 4 pages ofprofessional content (pagesS1, S2, S7, and S8), alongwith practical tips for puttingkey concepts into practice.

For your patients, there are 4pages (S3–S6) of easy-to-readinformation. There’s also aquiz patients can use to testtheir knowledge.

We encourage you to makecopies of In Control. Use it to supplement your owneducation materials, and callus at (800) 468-7777 if you wantto reprint an article. Helpyour patients get “in control”of their kidney disease!

In 2004, Fresenius Medical CareNorth America (FMCNA) intro-duced a company-wide programcalled UltraCare®—part of the organization’s commitment toongoing training for all employeesin innovative methods, the latesttechnology, and a shared focus onsuperior customer service. One ofthe key elements of the program isa renewed emphasis on “exemplarycustomer service.” Patti Gomez,Clinic Manager at FMC of Seguin,Texas, has seen a positive impacton her staff. Here are the details.

In-service Training“To earn annual UltraCare certifica-tion, every staff person in our cen-ter needed to participate in a seriesof in-service training sessions,”explained Gomez. Although thetopics and format of the sessionsvaried, there was a consistent focuson customer service and patient-staff relationships. Gomez thinksthe brainstorming exercises wereparticularly effective. Small groupsof 5 staff members—each groupincluded a mix of nursing, patientcare, office, and technical staff—were asked to come up with ideasfor improving customer service.

“In one session they concentratedon patient needs and expectations,and what staff could do to makesure that patients’ needs weremet,” said Gomez. In another session, staff identified challenges,then brainstormed ideas for posi-tive ways to tackle those chal-lenges. “These exercises reallyhelped our staff to get a different

perspective, and think a little moreabout the patient’s perspectiveof dialysis,” reported Gomez.

Staff AwardsAnother key element of theUltraCare program is the“Connection to Excellence”Awards for staff. Each quarter,every patient gets a form theycan use to name a staff memberwho they think has gone “aboveand beyond their duty” to pro-vide good care. The form isavailable in English andSpanish, and Gomez takes themaround to all patients. “They canfill them out anonymously, or fill intheir name if they prefer.Sometimes they just ask me to fill itin for them,” she said. “The staffperson with the most nominationsgets his or her name engraved on aplaque and also gets a gift certificate.”

According to Gomez, the“Connection to Excellence” awardsprogram has benefits for bothpatients and staff. “On the staffside, getting an award feels good,”claimed Gomez. “They can’t waitto know who won,” she added. “It’simportant to them to be noticedand appreciated.” In fact, Gomezthinks the recognition is almostmore important than the reward.“I ensure they get the recognitionthey deserve,” she noted.

On the patient side, Gomezbelieves that the award programgives patients the sense that theiropinions and comments are soughtout and important. “They feel

more comfortable commenting onboth good and bad,” she added,“and communication is better.”Gomez cited an example of apatient who nominated a staff person who didn’t move the TVaway after taking her off the dialy-sis machine, but instead let herwatch TV while she held her nee-dle stick site. “Everyone was sur-prised,” said Gomez “because thepatient had never said anything,but it was clearly important andthat one staff person had somehowpicked up on the concern.”

From her point of view, Gomezthinks UltraCare produces resultsbecause both the training and theawards keep staff “more aware of how they act toward patients.”And that, said Gomez, makes itmore likely that “we will treatpatients like we would want ourmother or father to be treated…and head off possible conflictsbefore they occur.”

www.lifeoptions.org www.kidneyschool.orgS2

FMCNA Program Rewards ExcellentCustomer Service

“We will treatpatients like

we would wantour mother

or father to betreated... and

head off possibleconflicts before

they occur.”

www.lifeoptions.org www.kidneyschool.org S3

Q: What is the best wayto help staff avoid con-flicts with patients?

Preparing patient care staff tounderstand fluctuations inpatient behavior as part of chron-ic illness is key. Understandingmakes a big difference in howteam members will react to diffi-cult situations. If staff memberscome to work with the attitudethat their needs as professionalsare equal to the needs of thepatient, it’s a recipe for conflict.When, on the other hand, staffunderstand that fear, anxiety,feelings of powerlessness,depression, and stress can cause“challenging” or “regressed”behavior during treatment, theyare much less likely to experi-ence it as a source of conflict.

Q: How do you preparenew staff members tohandle conflict?

Our initial training sessionsprovide a lot of information aboutexpectations. We teach our newteam members to expect conflict.And, we tell them why. In additionto the factors that go along withchronic illness, there is also thefact that almost 25% of our patientshave altered mental status—dueto anxiety, depression, substance

abuse, dementia, etc. Establishingrealistic expectations is the bestway to ensure that staff do notpersonalize difficult interactions.Next, we give our new teammembers a very clear protocolfor dealing with conflict. Itinvolves prompt reporting—usually within one hour—and agroup approach to debriefingand problem-solving. The resultis that staff members feel listenedto and supported, and can moveforward to approach the patientprofessionally to resolve the issue.

Q: Do you have anyongoing training formore experienced staff?

Keeping a good team attitudeabout difficult situations takesmaintenance. We focus on rein-forcing the protocol. We alwaysthank team members for reportingproblems and move quickly torespond to and resolve them. Thatway, team members don’t feel alone,and can remain professionally“empowered.” Often, involvedteam members come together withthe patient at a meeting designedto debrief a situation and create anew plan. Preparing the teammember for this experience fostersa willingness to approach the patientwith a good attitude. Staff learnto approach the patient by simply

asking: “We can see that you’ve beenupset, and we wonder what we couldhave done better.” That disarmsthe patient’s anxiety and anger andbrings forth their willingness. Then,the team members can ask forsomething they need in return fromthe patient...and the patient usuallycooperates. It is a win-win situation.

Q: What advice can youoffer about conducting asuccessful patient meeting?

In my experience, there aretwo “magic bullets.” The first isavoid “he did, she did” reporting.Rather, stick with the more for-ward-looking question of “Whatcould you/we have done better?”Second, focus on how each partycould improve and put both thepatient and the staff member inthe role of teacher. People liketo teach, and in 99% of the cases,we can find a solution that worksfor everyone. And, finally, don’tforget to reach down inside andhelp the team communicate that,underneath the conflict, they stillcare…that they want a positiveworking relationship. Patientsrespond to this with new hope. Andhope is the key to starting again.Please note that any comments made or opinions expressed here are her ownand do not necessarily reflect those of, nor are they necessarily endorsed by, her employer FMCNA.

Q & A:Ask the ExpertsAn interview with Stephanie Johnstone, LCSWClinical Social Work Supervisor, Fresenius Medical Care North America (FMCNA)—San Diego

Stephanie Johnstone supervises a team of nephrology social workers at FMCNA. She publishes frequently on nephrologysocial work topics, including conflict management. She has 20+ years of experience in nephrology social work.

A:

A:

A:

A:

empathize with patients so they can respond moreappropriately when a difference arises.

A patient-centered approach that includes learning the basis of patient behavior from the patient is alsofundamental to reducing conflict. For example, ask-ing why a patient is leaving treatments early mayreveal that he or she is trying to keep a job and sup-port a family. Knowing the reason enables the teamto problem-solve rather than begin a conflict that maylead to a patient discharge.

Using a Customer Service ApproachA better understanding of the “customers” of dialysisservices—the patients—is the foundation of a customerservice approach to care. Since virtually everyonehas been a customer with a complaint at some point,this model of care is highly relevant and easy toexplain to new trainees.

According to Berman, there are “7 C’s” of customerservice in the Renal Care Group customer relationsprogram. They are: communication, code of ethics(for staff), caring attitudes, collaboration, confidence,cultural sensitivity, and compassion.6

Focusing our efforts asa community on under-standing where ourpatients are comingfrom, improving train-ing and professional-ism, and implement-ing the 7 C’s has thepotential to help avoidconflict and make dialysis clinics calmer and more pleasant for patients and staffalike.

References1. Schwartz P, Rudavsky S, Christakis AN. Designing a collaborative

action plan with the ESRD stakeholders: A report of the Dialysis Patient-Provider Conflict (DPC). Forum of ESRD Networks, 2003

2. Curtin RB, Bultman Sitter DC, Schatell D, Chewning BA. Self-management,knowledge, and functioning and well-being of patients on hemodialysis.Nephrol Nurs J 31(4):378-87, 2004

3. Lowrie EG, Curtin RB, LePain N, Schatell D. Medical Outcomes StudyShort Form–36: A consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis 41(6):1286-92, 2003

4. ESRD Network 14. Involuntary Patient Discharge Survey, 2002

5. Russo R. Improving communication in patient-provider relations. J RenalSoc Work 23:53-6, 2004

6. Berman NZ. The seven C’s: Does improved customer service by the dialysis team equal improved patient satisfaction? Retrieved fromiKidney.com at http://www.ikidney.com/iKidney/InfoCenter/Library/CDN/Archive/CustomerService0503.htm

www.lifeoptions.org www.kidneyschool.orgS4

Preventing Conflict in Dialysis:The Value of Customer Service

In Control

Contact:Life Options Rehabilitation Programc/o Medical Education Institute, Inc.414 D’Onofrio Drive, Ste. 200Madison, WI 53719Tel: (800) 468-7777Fax: (608) 833-8366E-mail: lifeoptions@meiresearch.org

www.lifeoptions.orgwww.kidneyschool.org

Quiz Answers1. True2. False. It’s important

to report problems.3. False. Your timing

and manner makea difference.

4. True5. False. You are

more likely to get results if youremain calm.

(continued from page S1)

For more information about preventingconflict and providing excellent cus-tomer service in the dialysis centerask your ESRD Network for a copy of:• The DPC Toolbox: Conflict

Resolution Resources forDialysis Professionals.

To find your Network go to theForum of ESRD Networks website:www.esrdnetworks.org.

For More Information...

Problems sometimes arise at dialysis.Being on dialysis and dependent on amachine and clinic staff can be stressful.At the same time, many staff feel pres-sured to do a difficult and demanding job on a tight schedule. With all thatstress and pressure, it’s no wonder thatpatients and staff do not always see eye to eye.

Build RelationshipsYou’re much more likely to avoid con-flicts if you have honest, trusting rela-tionships with the staff who work withyou at the dialysis clinic. Treating thenurses and techs like people, not simply“your” caregivers, is a good start. Keepthe golden rule—treat others the wayyou’d like to be treated—in mind as astarting place.

Speak UpTreating staff members with respect, and

expecting themto do the samefor you, doesnot mean thatyou shouldkeep concernsto yourself. Onthe contrary!

Let staff members know if you’re havinga problem. The key to speaking up liesin how you do it.

Here are some tips:• Pick a good time, if you can. “When

you have a minute, I’d like to talk.”• Stay calm and reasonable. Don’t raise

your voice.• Be specific. Describe the problem and

say how it makes you feel.• Use “I” statements like “When my treat-

ments don’t start on time, I feel like theclinic doesn’t respect my time.”

• Talk about the behavior not the person. For example, “I prefer the TV volume to be set on low,” rather than “You turnthe TV volume too loud.”

• Avoid “you” statements like “You alwaysstart my treatment late.”

• Match your body language to yourwords. Don’t smile if you’re angry.

Follow ProceduresPreventing problems is always betterthan trying to fix them. But, if you dohave a problem, it is important to dealwith it in the right way. Your clinic has

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How to Handle a Problem at Your Dialysis Clinic

A Medical Education Institute/Life Options Publication

VOL. 2 | NO. 4

DECEMBER 2005

Patients

P1

Patients

In Control is supported by Amgen Inc.

and published in cooperation with

(continued on page P4)

Colorado native Jonathan Finger raninto one of the most common sources of conflict at his clinic: trouble cannulatinghis fistula that led to infiltrations. Heworked with his clinic administrator tosolve the problem, and, a year later, thingsare much better. Here’s his story.

IgA NephropathyAs early as 5th grade, Jonathan, now 28,knew he had a problem: Berger’s disease(IgA nephropathy) was attacking hiskidneys. The condition had not causeda loss of function, and wasfollowed with regularblood tests until 1998.

“I was getting ready tomove overseas for a year-long apprenticeship inBraunschweig, Germany, at a piano factory,”recalled Jonathan, who works full-time asa rebuilder and technician in his family’spiano store. “They did some bloodworkand said, ‘you’ve lost 45% of your kidneyfunction.’ That was kind of a big blow.”

Following a biopsy, Jonathan spent theyear in Germany, taking fish oil to slowthe progress of his disease, then camehome with 10% function and got readyfor a transplant from his mother. Thetransplant lasted 2 years before it failed.

Choosing In-centerHemodialysis“I’m kind of a thinker personality,”

Jonathan noted. “I reviewed the optionsand coming into the center felt like astructure I needed. I was willing to give them the time, and in exchange, I was able to not think about it for a couple of days. As long as there’s anadministrator or a charge nurse I trust, I feel like it’s a safe place. It allows meto keep dialysis separate from my life.There’s a part of me, psychologically,that doesn’t want to bring it into myhome.”

“I’ve been reallyblessed,” he added. “I dialyze in the after-noons, so I leave workearly a couple of daysa week, and then acouple of other days

I work later. The way I’ve been able tostructure it, it fits well with work.”

Coping with CannulationGood needle skills are key to helping afistula last as long as possible. WhenJonathan noted problems with staff whowere sticking him—and a trusted nurseand technician quit—he knew he had totake action.

“I had had some problems with infiltrationand thought they were 100% avoidable, a couple of times in particular,” hereported. “The technicians didn’t listento me when I told them that the stick

www.lifeoptions.org www.kidneyschool.orgP2

Heading Off Conflict Through Communication

PatientsPatients

“[The administrator] made me feel like she was concerned, and in the end, that was what

I was looking for.”

www.lifeoptions.org www.kidneyschool.org

felt wrong going in. Or, when a techni-cian was having trouble cannulating,instead of getting the nurse right off the bat, they kept trying out of pride.”

Calling the Administrator“In the end,” said Jonathan, “it was my treatment and my life, and everyoneelse’s at the clinic. I called up the admin-istrator, Lori. I felt the best way was toapproach it like they were a business and I was a customer, and give her achance to earn my business—to make it right. So I had a pretty open chat with her about things I liked and things I didn’t like, and that I understood thatsome people had more experience andsome had less. It wasn’t that I didn’t like them, but I didn’t trust them—theywould watch TV with us, or trip overthings and knock them over. Or theydidn’t notice where the tape was, andwould start pulling on a needle.”

“Lori’s smart and forward looking, andshe saw how she could change things,”Jonathan explained. “She made me feellike she was concerned, and in the end,that was what I was looking for.”

Finding a SolutionLori took action. She shifted staff schedules so less knowledgeable staffcould learn from their more experiencedcoworkers, rather than always having the same team for MWF and TRS shifts.

And she added a new full-time nurse toease staffing concerns.

The results were worthwhile, accordingto Jonathan. “Now, you have more expe-rienced techs working with the othertechs, and as a result, everybody is ableto raise the bar a bit. If you have a cou-ple of techs who are doing a good job,they can show the others. They shareinformation.”

Raising the BarBesides resolving Jonathan’s cannulationconflict, Lori took another step to improvecustomer service: she authorized a wire-less Internet network. For Jonathan, whohas an on-line web “blog” about his dialy-sis experiences (at www.tollidee.com)this was the icing on the cake. “I reallyappreciate Lori’s willingness to listen andto make things better for everybody,” he concluded.

P3

PatientsPatients

a process for making complaints. Besure you know what it is—and follow the steps. Because you will be expectedto provide specifics, write down all thedetails of your complaint, includingdates, times, what happened, who wasinvolved, what was said, and how youtried to solve the problem.

Kidney School™ Can HelpWould you like to know more about yourrights and responsibilities as someoneon dialysis…and how to handle prob-lems in your clinic? Kidney School canhelp. Kidney School is the on-line, per-sonalized kidney learning center createdby Life Options. Module 14—Patient

Rights and Responsibilities—has detailedinformation about your rights as apatient and a step-by-step process forhow to file a complaint. This helpfulmodule will also help you learn aboutother key issues like privacy, switchingclinics, getting second opinions, andchanging your treatment. KidneySchool is free—and can be accessed atww.kidneyschool.org.

If you don’t have a computer at home,try the library. Or, ask a friend or relativeto help you log on so you can use thisvaluable resource. Your ESRD Networkis a valuable resource if you cannotresolve the problem with your center.

www.lifeoptions.org www.kidneyschool.orgP4

How to Handle a Problem at Your Dialysis Clinic(continued from page P1)

Now that you’ve read about how to handle problems in your dialysis clinic, try toanswer the true/false statements below to see how much you’ve learned (answersare on page S8).1. Every clinic has a formal process for

complaints. r True r False2. You should avoid upsetting staff members by

keeping problems to yourself. r True r False3. It doesn’t matter how you voice your complaints,

as long as you’re honest. r True r False4. Dialysis patients need to treat staff members

with respect. r True r False5. If you’re serious about making a complaint,

you need to show it—even if you have to shout. r True r False

Problem Quiz

PatientsPatients

In Control

Contact:Life Options Rehabilitation Programc/o Medical Education Institute, Inc.414 D’Onofrio Drive, Ste. 200Madison, WI 53719Tel: (800) 468-7777Fax: (608) 833-8366E-mail: lifeoptions@meiresearch.org

www.lifeoptions.orgwww.kidneyschool.org