D. Viker, RN, BSN; P. Gill, RN, BSN; G. Faley, RN; S. Hartvikson, RN; J. Wageman, MS, RN,CNN; T.V. Neumann, MD; J. Jessop, MS, RN, CNA; D. Istas, MA, RN, CHN; L. Buttry, RN; M.A. Martin, RN, CNN; M. Miller, BSN, RN; P. Stanton, RN, CNN;D. Heimann, RD, LMNT; A. Tran; M. Holland, RN; T. Staats, RN; B. Mar, RD;D. Fender, RN, BSN, CHN, MBA; J. Brase, RN, MSN; D. Hage, RN, CNN; P. Sinclair, RN, CNN

CQI Process Improves Peritoneal Dialysis Adequacy

Worldwide, dialysis adequacy has emerged as a key issue. It has been recognized that inad-equate dialysis may result in the retention of uremic toxins, which can, among other things,suppress appetite and result in malnutrition and morbidity. In January 1996, an Ad HocCommittee on Peritoneal Dialysis Adequacy concluded that: 1) the dialysis prescriptionmust be individualized; 2) by doing so, the suggested clearance guidelines can be achievedin almost all patients; 3) a wide range of regimens are available for individualizing the pre-scription; and 4) well-prescribed peritoneal dialysis (PD) is an excellent therapy for the ma-jority of patients. According to the 1997 NKF-DOQI™ Clinical Practice Guidelines forPeritoneal Dialysis Adequacy, the delivered dose for CAPD should yield a total Kt/Vurea of atleast 2.0 per week, and a total creatinine clearance (CCr) of at least 60 L/week/1.73 m2. Manydialysis centers across the U.S. have implemented a continuous quality improvement (CQI)process to help improve dialysis adequacy. RenalWest Home Dialysis in Phoenix, AZ, im-proved their program’s dialysis adequacy to the point where 80% of their patients met tar-geted adequacy markers within a 6-month period. Nebraska Health Systems/ClarksonKidney Center in Omaha, NE, increased their understanding of PD adequacy by establish-ing a routine protocol for determining adequacy and by offering education on adequacystudies for all unit members. Satellite Dialysis Centers in Modesto, CA, discovered that 39%of their patient population had dropped out of PD. They implemented a CQI process to helppatients achieve their adequacy targets and reduce PD dropout. As the recommendations ofthe Ad Hoc Committee gain widespread popularity, improving dialysis adequacy will be-come more achievable through the implementation of proven CQI processes.

orldwide, dialysis adequacy isemerging as a key issue. It hasbeen recognized that inadequate

dialysis may result in the retention of ure-mic toxins, which can, among other things,suppress appetite and result in malnutritionand morbidity.

Two aspects of assessing the adequacy ofthe dialysis prescription include the minimal-ly acceptable prescription and the optimalprescription. The minimally acceptable pre-scription avoids the more overt symptoms ofuremia and ensures acceptable short-termtherapy outcomes. The optimal prescriptionprovides long-term clinical outcomes, i.e.,lower morbidity and mortality, better patientrehabilitation, and improved quality of life.1

The differences in cause-specific mortali-ty among patients treated by peritoneal dial-ysis (PD) or hemodialysis (HD) may be dueto the technical differences between the twomodalities and/or differences in patient com-pliance, medical care, and dose of dialysis.As a result of studies showing a relationshipbetween dialysis dose and mortality, the pre-scribed dose among the U.S. hemodialysispopulation has increased substantially.2 Asimilar relationship has also been foundamong PD-treated patients and has stimulat-ed an interest in increasing the dialysis dosein this population as well.3

Differences in case-mix severity amongthese two patient groups might also play arole in patient outcomes, although previous

WD. Viker, P. Gill, G. Faley, andS. Hartvikson are with Renal-West Home Dialysis of Phoenix,Arizona; J. Wageman, T.V. Neumann, J. Jessop, D. Istas, L. Buttry, M.A. Martin, M. Miller, P. Stanton,and D. Heimann are with Nebraska Health Systems/Clarkson Kidney Center, Omaha, Nebraska; A.Tran, M. Holland, T. Staats, andB. Mar are with SatelliteDialysis Centers, Inc., Modesto,California; D. Fender, J. Brase,D. Hage, and P. Sinclair arewith Baxter Healthcare Corpo-ration, McGaw Park, Illinois.

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studies have shown relatively smalldifferences in comorbidity betweenPD- and HD-treated incident pa-tients.4 Overall, the mortality rate ofboth HD and PD patients during thefirst year of end-stage renal diseasehas been shown to be very similar.5

There has been a progressive im-provement in first-year survival foreach successive year’s incident cohortsince 1985. A possible explanation forthe decline in mortality is that changeshave been made in the way that thedialysis therapy is practiced.6 In par-ticular, during this period the renalprovider community has given in-creasing attention to the dose of dialy-s i s tha t i s de l ive red to thehemodialysis patient.6 In addition,there have been changes in the dialy-sis equipment being used, including ashift from cellulosic to synthetic he-modialysis membranes and improvedconnection devices for peritoneal dial-ysis. The use of recombinant humanerythropoietin has also continued toincrease during this time period.6

As improvements in deliveredcare continue to spread throughoutthe community of renal providers, wemay see continued improvements inpatient survival across the nation.7

Defining Adequacy of DialysisCurrent-day practices have been shift-ing away from minimally acceptabledialysis prescriptions to achieving op-timal dialysis dose. To do this, kineticmodeling is being used to evaluate thedelivered dose and to adjust prescrip-tion levels accordingly. In both he-modialysis and peritoneal dialysis,there is an increasing awareness of theneed to adjust prescriptions in order tomaintain adequate clearances as resid-ual renal function declines.8

With a larger number of patientsnow being placed on continuous ambu-latory peritoneal dialysis (CAPD), theissue of adequate therapy is becomingeven more significant. In the past,residual renal function and peritonitishave conspired to mask the magnitude

of the problem of inadequate therapy.Since this is no longer the case, theneed to quantify and individualizethe therapy prescription has becomeeven more pronounced.9

An Ad Hoc Committee on PeritonealDialysis Adequacy was convened inJanuary 1996 by Baxter HealthcareCorporation in order to develop a con-sensus statement including clinical rec-ommendations for improving PDadequacy. The committee’s focus wason defining clearance targets and guide-lines for achieving adequacy, rather thanon all of the parameters, such as nutri-tion, that comprise PD adequacy.

The committee—consisting of in-vited experts from the U.S. andCanada—recommended that peri-toneal dialysis prescriptions be tai-lored “to provide the most dialysisthat can be delivered to the individualpatient, within the constraints of so-cial and clinical circumstances, qual-ity of life, lifestyle, and cost.”9 Thecommittee concluded that:

• The PD prescription must be indi-vidualized. There is no standard,one-size-fits-all prescription.

• By individualizing the prescription,the clearance guidelines suggestedby the Ad Hoc Committee on Peri-toneal Dialysis Adequacy can beachieved in almost all patients, eventhose with no residual renal func-tion.

• A wide range of PD regimens areavailable to assist in individualizingprescriptions and achieving ade-quacy guidelines.

• Well-prescribed PD is an excellenttherapy for the majority of patients.The challenge to individual practi-tioners is to make prescription man-agement an integral par t ofeveryday patient care.10

Today, based on the 1997 NKF-DOQI™ Clinical Practice Guidelinesfor Peritoneal Dialysis Adequacy, thedelivered dose for CAPD shouldyield a total Kt/Vurea of at least 2.0 perweek, and a total creatinine clearance

(CCr) of at least 60 L/week/1.73 m2.Theoretical constructs predict that

a weekly peritoneal Kt/Vurea between2.0 and 2.25 will provide adequatedialysis, assuming:

• no residual renal function;

• full equilibration of plasma anddialysate urea;

• target serum urea nitrogen concen-tration between 60 and 80 mg/dl;

• normalized protein catabolic ratebetween 1.0 and 1.2 g/kg/day.

Studies show that outcomes aresuperior with doses of PD that arehigher than previously accepted(weekly Kt/Vurea of 1.7) and supportthe previously mentioned figures astargets to achieve that will correlatewith acceptable outcomes.11

CASE STUDIES

RenalWest Home DialysisRenalWest Home Dialysis, Phoenix,AZ,12 improved their program’s dialy-sis adequacy to the point where 80%of their patients met targeted adequacymarkers by the end of December 1995.(Note: Today’s targets are higher.)

Data collected every 6 months atthe center highlighted the fact that30% of the program’s 188 PD patientswere failing to meet targeted adequacyparameters, thus affecting patient well-being and nutrition. Their objectivewas to improve adequacy of dialysisfrom 70% to 85% of the program’s pa-tients by meeting targeted adequacyparameters of Kt/V >1.7, and a creati-nine clearance of >50 L/week normal-ized to 1.73 m2 body surface area.

Data CollectionThe CQI team analyzed adequacydata over a 1-year period regardingthe top five potential causes of theirproblem. Their goals were to:

• Examine compliance in patientswho failed to meet adequacy targets.

• Review the staff education processfor adequacy.

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• Evaluate how the prescription mod-eling tool was being used.

• Determine the percentage of pa-tients who had physician approvalto maintain current dialysis pre-scriptions even though they failedtarget parameters.

• Evaluate the emphasis given to ade-quacy testing during patient training.

Data AnalysisAn average of 15–20% of patientswho failed adequacy targets in theprogram were non-compliant to pre-scribed therapy. Patients failed toreach specified adequacy markerswhen they failed to bring in theirspecimens and/or allowed 6 monthsto elapse between the performance ofadequacy testing. This led to delaysin prescription changes resulting inunderdialyzed patients for longer pe-riods of time.

Patients’ understanding of the im-portance of testing might influencetheir compliance. Many patients hadnot had PET or PFT testing performed.

Solution SelectionA force field diagram (also calledsolution analysis)i was used to iden-tify restraining and driving forces.Each solution was evaluated to de-termine the number of restrainingforces that it would influence. Stafftraining and education influenced allseven of the identified restrainingforces. Group training in the patien-t’s own language, social work re-source programs, and use of anautomated PD cycler (Home Choice,Baxter Healthcare) each influencedthe restraining forces.

The team concluded that patientcompliance could be influencedthrough staff training. A 60-day periodwas identified as necessary to imple-ment an action plan and to ensureenough time for the interventions to in-fluence adequacy results and demon-strate a decrease in the percentage ofpatients failing adequacy targets.

Implementation PlanIt was agreed that staff educationwould be accomplished while revisingthe patient training manual. Researchto prepare the adequacy section of themanual would provide reinforcementof adequacy theory. The patient carestaff ended up changing the adequacymodeling programs for purposes ofease-of-use, support, and updatedsoftware. The team decided that somereeducation on adequacy could be ac-complished along with education onthe use of the new computer modelingmethod.

Nursing inservices would targetthe importance of membrane testingand the use of dwell time and volumeto enhance dialysis adequacy. Dieti-tians would review the computermodeling method’s monitoring of nu-tritional markers, and PD adequacymeasurements were taken by lookingat the percentage of patients who didnot have prescriptions adjusted afterfailing to meet adequacy targets. Ahigher percentage of PD patientsmeeting adequacy targets after imple-mentation of the plan was expected.

Testing the SolutionFrom a select test group of patients re-flecting 10% of the patient popula-tion, baseline data on Kt/V, creatinine

clearance, current dialysis prescrip-tions, and residual renal function werecollected. With these data, the primarycare nurses would be able to managethe patients’ prescriptions, with physi-cian approval, based on informationgained through adequacy training andcompetency testing. The same datawere collected and reviewed at the endof a 6-month period to determinewhether the patients’ adequacy levelsmet the program’s criteria.

ResultsA 6-month time frame was used toevaluate test group data, allowing for:

• staff evaluation of the prescription;

• physician approval;

• implementation of the prescription;

• the patient to reach a steady state onthe prescription;

• a follow-up evaluation for adequa-cy of the prescription.

Overall, the results demonstratedthat staff training and education im-pacts patient compliance to pre-scribed therapy and improves theadequacy of the dialysis.

Nebraska Health Systems/Clarkson Kidney CenterNebraska Health Systems/ClarksonKidney Center, Omaha, NE,13 realizedthe importance of determiningwhether their patients were being ade-quately dialyzed and, if not, improvingtheir dialysis prescriptions. Dialysisadequacy studies were not routinelyperformed unless patients were show-ing clinical symptoms of inadequatedialysis and/or had significant changesin their monthly chemistries.

i Solution analysis, also called “force field” analysis, is a tool that enables centers to analyze selected root causes in greater detail. It is used to define exactlywhy a problem or issue exists and to identify potential solutions to overcome those problems. It also helps determine possible next steps in the process. Thetime to use force field analysis is during the brainstorming process, to identify all possible issues that could be a part of the solution. Force field analysis isperformed diagrammatically by identifying the most significant root cause and then a list of contributors to that root cause. This list can also be used to iden-tify “Restraining Forces” that keep a problem at its current unresolved level. The next step is to brainstorm for possible solutions. It is important to identifyat least one solution for each cause. Some of the solutions, or “Driving Forces,” will impact more than one barrier. Determine all possible solutions for eachcause and draw an arrow from each possible solution to all of the causes it impacts. Each restraining force should have at least one driving force to counter-act it. After identifying solutions through solution analysis, it is necessary to determine which solution(s) should be implemented based upon a number ofagreed-upon criteria. These criteria should include, but are not limited to: the solution with the highest potential impact, the solution that is easiest to fix/mea-sure, ease of implementation, cost, practicality, speed of implementation, and the team’s ability to implement the solution.

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The objective of the CQI process im-plementation was to increase the knowl-edge and understanding of dialysisadequacy for peritoneal dialysis pa-tients. The CQI plan established a rou-tine protocol for determining whether ornot a patient was adequately dialyzed.Home dialysis unit coordinators becamemore proficient in performing and eval-uating adequacy studies.

Root Cause Analysis,Solution Analysis, and SolutionAnalysis MatrixRoot cause analysis identified manyfactors contributing to the problemand helped to organize them so that theteam could readily see the relationshipbetween those factors and the currentprocess. Solution analysisi and brain-storming assisted in showing whichsolutions would work well to resolvethe problem. A solution analysis ma-trix was used to rate possible solutionsbased upon likelihood of success.

SolutionsTwo priority solutions were identi-fied:• Set up an educational offering on

dialysis adequacy for unit members.• Develop a patient tracking flow

sheet that would include the collec-tion of data on all current patientsto determine who had previouslyundergone adequacy studies, aswell as the results of those studies.

Data CollectionUnit members collected data on theirprimary patients and discovered that animportant clinical need had not beenmet: Only 35 of 80 current patients hadbeen quantitatively evaluated for theirdialysis adequacy at any point in theirtherapy. Unit members realized thatthey needed to understand the entireadequacy modeling report in order tomake necessary changes in patientdialysis prescriptions.

Home dialysis unit coordinators at-tended an educational inservice that re-viewed peritoneal dialysis adequacy,including Medicare’s standards, and theresults of their patients’ collected data.Twelve of the 35 patients were identi-fied as having had prescription changesmade with no retesting. Nine patientswere identified who were just belowMedicare standards for Kt/V and crea-tinine clearance. Prescription adjust-ments for these patients were evaluated.

CQI Action PlanAn action plan was developed, assign-ments were made, and a progress re-port session was scheduled. All PDpatients would have dialysis adequacystudies performed on a routine basis,including a peritoneal equilibrationtest (PET), dialysate urea and creati-nine clearance studies, and evaluationof residual renal function.

The home dialysis nurses identi-fied 10 patients from the TARGETReportii who could be retested fordialysis adequacy. These patientswere selected based on the fact thatthey were 1) still on peritoneal dialy-sis, and 2) could be retested.

In addition to these 10 patients, theunit coordinators prioritized their pri-mary patients for the scheduling ofadequacy studies. Using the Medi-care-recommended minimum guide-lines for Kt/V (≥1.7/week) andcreatinine clearance (≥50 L/week/1.73m2

BSA), quantitative parameters forreaching dialysis adequacy were cho-sen. Baxter’s Prescription Manage-ment Decision Tree for PD Adequacyand the patient modeling componentof the PD Adequest Program wereused to assist with making dialysisprescription changes.

Future StepsThe CQI team determined that routineadequacy tests would be performedon all patients every 6 months. The

PET would be repeated if mem-brane changes were suspected. NewPD patients would have their initialPET and adequacy studies per-formed approximately 1 month af-t e r c o m p l e t i o n o f t r a i n i n g .Adequacy studies would be repeat-ed after therapy changes were com-pleted upon agreement of the homedialysis unit coordinator and med-ical director on an individual basis.Patients who showed other clinicalsigns of inadequate dialysis mighthave the i r adequacy s tud iesrechecked more frequently than theevery-6-month schedule.

The center’s adequacy program(PD Adequest, Baxter Healthcare)will continue to be a major source fortailoring individual patient therapiesand evaluating dialysis adequacy.Quarterly summaries of the popula-tion’s adequacy results will be gener-ated and presented to the team, andthen shared with the rest of the kid-ney center. Expansion of this study toassess and improve other patient out-comes is planned.

Satellite Dialysis CentersThe CQI team at Satellite DialysisCenters, Modesto, CA,14 discoveredthat 39% of their total patient popula-tion dropped out of peritoneal dialysiseither due to death or a switch to in-center hemodialysis. They examinedthe common problems of these pa-tients and identified all possiblecauses for death or return to in-centerhemodialysis. They discovered thatthese patients had either albumin lev-els of less than 3.0 g/L, a Kt/V<1.7/week, or a creatinine clearanceof less than 50 L/week. Adequacy ofdialysis was selected as an improve-ment opportunity because the out-comes are measurable within a shortperiod of time. The goal for all iden-tif ied patients was set at 75%achievement of adequacy targets.

ii A Baxter-generated report from PD Adequest™ data, which is a computerized PD prescription model that helps develop PD prescriptions using clinical judg-ment on adequacy as a program input. TARGET stands for Treatment Adequacy Review for Gaining Enhanced Therapy outcomes.

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Root Cause AnalysisUsing a root cause analysis, the teamidentified the top three issues of pa-tient dropout as:

• low Kt/V and creatinine clearance

• exit site infection

• surgeon’s technique

Data CollectionData collection substantiated theneed to reassess dialysis prescrip-tions on 11 patients in order to reachthe adequacy target. After identifyingthose patients who did not meet thesetargets, regimens were modeledthrough use of an adequacy program(PD Adequest, Baxter Healthcare).Regimens were chosen that wouldachieve adequacy targets and fit eachpatient’s lifestyle. From 24-hour ade-quacy tests, results were analyzed us-ing this program, and the Kt/V andcreatinine clearance were document-ed. Patients’ current regimens withactual Kt/V and creatinine clearancelevels were assessed and comparedwith the predicted Kt/V and creati-nine clearance in order to determinepossible noncompliance.

Solution SelectionThe following solutions were consid-ered:

• Provide patients with statisticalproof of consequences of ade-quate/inadequate dialysis.

• Reinforce the benefits of achievingthe adequacy goal to patients, i.e.,prolonged life expectancy, im-proved appetite, increased sex drive,and the ability to feel better andmaintain as normal a lifestyle aspossible while on dialysis.

• Increase fill volume gradually ifpatient is reluctant to increase vol-ume immediately.

• Offer patients regimen choices suchas CCPD, APD, and Home Choice(Baxter Healthcare) when appropri-ate in order to free up the patient’stime during the day.

In a 5-month period of time, itwas anticipated that patients wouldshow improvement in adequacy. Thehome dialysis unit coordinatorsspent time discussing adequacy is-sues with patients and answeringquestions. Patients were encouragedto visit their nephrologist once amonth, at which time the physicianwould reinforce the changes madeon the patient’s prescription and dis-cuss the benefits of reaching adequa-cy targets.

Benefits of Adequacy ImprovementPatient benefits from adequacy im-provement include feeling better, be-ing able to maintain a normallifestyle as much as possible, and de-creasing the chance of hospitaliza-tion. Additionally, physicians don’thave to spend extra time followingup with patients in the hospital, thecosts of medical care are decreased,and the number of patients leavingPD is reduced.

Developing an Implementation PlanThe home dialysis unit coordinatorsbegan discussing adequacy issueswith individual patients over thetelephone prior to the patient’sscheduled visit to the unit. Topics ofdiscussion included the conse-quences of adequate/inadequatedialysis, computer modeling, and thechoice of regimens available toachieve the adequacy target. Nursesdivided the responsibilities of patientsupply delivery and inventory man-agement, gathered statistics and de-veloped a form to share informationwith the patients, and used the com-puter program to model patients.

Weekly meetings were held tofollow up on action plan implemen-tation. Upon completing the actionplan, patients received new sup-plies and began their new prescrip-tion. Their Kt/V was checked after1 month into the prescriptionchange, and Kt/V results were, asexpected, higher.

CONCLUSIONContinuous quality improvementprocess implementation is instrumentalin helping dialysis centers improveadequacy in their peritoneal dialysispatients. As recommendations fromthe January 1996 Ad Hoc Commit-tee on Peritoneal Dialysis Adequacyand the 1997 NKF-DOQI ClinicalPractice Guidelines for PeritonealDialysis Adequacy gain widespreadpopularity, improving dialysis ade-quacy will become more achievable,and more manageable, with the helpof a CQI process.

Once patients are identified, ade-quate clearances delivered by PD canbe achieved in almost all patients ifthe prescription is individualized ac-cording to the patient’s body surfacearea, amount of residual renal func-tion, and peritoneal membrane trans-port characteristics.

The future of adequacy improve-ment is moving from only specifyinga single clearance or Kt/V target toproviding the most dialysis that canbe delivered to the individual patient,within the constraints of social andclinical circumstances, quality oflife, lifestyle, and cost.

PD practitioners are challenged tomake prescription management anintegral part of everyday patientmanagement, including assessmentof peritoneal membrane permeabili-ty, measurement of dialysis andresidual renal clearance, and adjust-ment of the dialysis prescriptionwhen indicated.10 This can be facili-tated with implementation of a CQIprocess in the dialysis center.

References1. Keshaviah P. “Assessing Dialysis Adequa-cy.” Baxter Healthcare Corporation, 5K9253,1993, a monograph based on “Implications ofthe urea kinetic and middle molecule ap-proaches to assessing the adequacy of he-modialysis and CAPD,” Kidney Int 1993; 43(suppl 40) and “Adequacy of CAPD: Aquantitative approach,” Kidney Int 1992; 42(suppl 38).

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2. U.S. Renal Data System. USRDS 1996 An-nual Data Report. Bethesda, MD: NationalInstitutes of Health, National Institute of Dia-betes and Digestive and Kidney Diseases,1996.3. Canada-USA (CANUSA) Peritoneal DialysisStudy Group. Adequacy of dialysis and nutri-tion in continuous peritoneal dialysis: Associa-tion with clinical outcome. J Am Soc Nephrol1996; 7:198-207.4. Held PJ, Port FK, Turenne MN, Gaylin DS,Hamburger RJ, Wolfe RA. Continuous ambula-tory peritoneal dialysis and hemodialysis: Com-parison of patient mortality with adjustment forcomorbid conditions. Kidney Int 1994;45:1163-1169.5. Held PJ, Wolfe RA, Ashby VB, Orzol SM,Port FK, Golper T. Cost-effectiveness of he-modialysis compared to peritoneal dialysis. J AmSoc Nephrol 1997; 8(1):219A.6. U.S. Renal Data System. USRDS 1997 An-nual Data Report. Bethesda, MD: National In-stitutes of Health, National Institute ofDiabetes and Digestive and Kidney Diseases,1997.7. U.S. Renal Data System. USRDS 1998 AnnualData Report. Bethesda, MD: National Institutesof Health, National Institute of Diabetes and Di-gestive and Kidney Diseases, pp 84, 69-70, 1998.8. “Options in Renal Therapy: Renal TherapyOverview.” Baxter Healthcare Corporation,5K9250, 1994.9. Keshaviah P. Urea kinetic and middle mole-cule approaches to assessing the adequacy of he-modialysis and CAPD. Kidney Int 1993;43(suppl 40):S-28-S-38.10. Blake P, Burkart JM, Churchill DN, Dau-girdas J, Depner T, Hamburger RJ, Hull AR,Korbet SM, Moran J, Nolph KD, OreopoulosDG, Schreiber M, Soderbloom R. Recom-mended clinical practices for maximizing peri-toneal dialysis clearances. Perit Dial Int 1996;16:448-456.11. NKF-DOQI™ Clinical Practice Guidelinesfor Peritoneal Dialysis Adequacy (Guideline15). New York: National Kidney Foundation,1997.12. Viker D, et al. “Adequacy of Dialysis Study(1995): RenalWest Home Dialysis of Phoenix,Phoenix, Arizona.” Baxter CQI Educational As-sistance Award Winner, 1996.

13. Wageman J, et al. “Development of Routine

for Evaluation of Peritoneal Dialysis Adequa-

cy: A Continuous Quality Improvement Process

(1996): Nebraska Health Systems/Clarkson

Kidney Center, Omaha, Nebraska.” Baxter CQI

Educational Assistance Award Applicant,

1996.14. Tran A, Holland M, Staats T, Mar B, Sin-clair P. “Adequacy (1995): Satellite DialysisCenters, Inc., Modesto, California.” BaxterCQI Educational Assistance Award Winner,1996. D&T

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