Needed improvements are presented to the dialysis unitand should be implemented before the auditing teamrevisits the unit, which is normally once a year.A system of QM consists of projects that examine and

improve what we do and how we do it, but also what wedonot have ordo.For instance, by implementing in dailyclinical practice a vascular access program thatmeasuresaccess flow and prescribes the actions to take when flowdecreases, the number of vascular access clotting inci-dents can be reduced (Fig. 2). As a result, the number ofadmissions and operations for vascular access clotting isreduced.A system of QM is therefore a new proactive way of

doing things saves money and time. It concentrates onfinding and fixing problemswith processes, not people. Itstrives to eliminate problems permanently. But of majorimportance is that it is a mindset, a new way of thinking.In order to evaluate the improvement in quality, adefinition of quality must be given in advance. Thisdefinition is an optimization of treatment qualityaccording to given standards. Moreover, not only mustquality bedefined, but alsowhat ismeant ormeasuredbyoutcome.

Discussion

As in any typical ISO system, the focus is onguaranteeing the quality of processes to ensure thequalityof theoutcome.Hencea systemofQMfocusesonthe completeness, repeatability, and transparency of theprocesses. It is a comparisonwith prior performance, it isa multidisciplinary approach, and it is a continuingprocess. However, so far no mention has been made ofexpectedoutcomes, neither inquality of cure termsnor inefficiency gains, effectiveness gains, or customer satisfac-tion gains. The ‘‘old’’ ISO 9000 series terms themselvesare partly to blame and the revised ISO standardstructure should be less procedural and focus more oncustomer requirements (10). Moreover, it must beadmitted that defining quality in this specialized area ofhealth care is not easy.Crucial in the discussion on quality in health care is

the problem of quality of cure versus quality of care,where opinions differ about the relative weight of thetwo variables. Also useful in this context is the

distinction between ‘‘quality of core service’’ and‘‘quality of surrounds,’’ where quality of cure parame-ters obviously tend to prevail (11). This tends to be thecase in dialysis as well. Dialysis is an ‘‘archetype of QM,because the cure is so easily measured’’ (12). Theimportance of cure parameters is underlined by the factthat ‘‘quality of life experienced is determined most bythe quality of the renal service supporting the patient.High clearance rate and few complications offer signi-ficant enhancement in physical and psychologicalquality of life’’ (13).So, whereas quality of cure can be objectified and

seems to have an impact on the general quality indialysis to a large extent, in a QM model with itsfocus on customer satisfaction, the quality of carefrom a patient perspective is vital as well. Patientpriorities have been investigated in several studies.The most frequently found elements impacting patientsatisfaction in dialysis environments are informationand explanation of treatment, availability of the nurseor doctor, nurse/patient relationship, and amount oftime spent per patient (12,14,15). By developing asystem of QM, which guarantees the certification ofall processes focusing on treatment of patients, onemay be able to reduce morbidity and mortality,improve quality of life, and improve patient satis-faction.In conclusion, an integrated evaluation of system

processes and outcome parameters in dialysis may leadto quality assurance. Although the system has to beevaluated, it can be hypothesized that total QM maylead to better results, transparent finances, and mightbe macroeconomically cost effective. From a futureperspective, it can be hypothesized that dialysis centerswhich do not meet the criteria for QM may receive lessmoney for renal replacement therapies; in other words,coupling certification and quality standards withreimbursement. An evaluation of the QM system in2–3 years may shed light on its efficacy in daily clinicalpractice and whether the system leads to better careand cure.

References

1. Eknoyan G, Levin NW, Steinberg EP: The dialysis outcomes quality ini-tiative: history, impact, and prospects. Am J Kidney Dis 35(suppl 1):69–75,2000

2. Hansson J: Quality in health care: medical or managerial? Managing ServQual 10:78–81, 2000

3. WuAW,FinkNE,CagneyKA, Bass EB,RubinHR,MeyerKB, Sadler JH,Powe NR: Developing a health-related quality-of-life measure for end-stagerenal disease: theCHOICEhealth experience questionnaire.AmJKidneyDis37:11–21, 2001

4. Geber B: Can TQM cure health care ? Training 29:25–34, 19925. Bergman R: Not-for-profits may get a shot at prestigious quality award.

Hosp Health Networks 68:82, 19946. Lim PC, Tang NKH: The development of a model for total quality health-care.Managing Serv Qual 10:103–111, 2000

7. Connelly J: A realistic theory of health sector management: the case forcritical realism. J Manage Med 14:262–271, 2000

8. Stichting Harmonisatie Kwaliteitsbeoordeling in de Zorgsector. Harmoni-satiemodel voor Externe Kwaliteitsbeoordeling gericht op Certificatie in deZorgsector, 1996

9. Stichting Harmonisatie Kwaliteitsbeoordeling in de Zorgsector. Certifica-tieschema Dialysecentra; Sectorspecifieke Deel. Maart, 1999

10. Drickhamer D: Standards shake-up. Industry WeekMarch:, 2001

Fig. 2. The number of vascular access operations (white boxes)

and the number of PTA for vascular access (black boxes).

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11. Peters J, Sandison G: Quality assuring professional practices: a caseexample from a cancer treatment center. Managing Serv Qual 8:231–234,1998

12. Alexander GC, Sehgal AR: Dialysis patient ratings of the quality of medicalcare. Am J Kidney Dis 32:284–289, 1998

13. Haycox A, Jones D: The cost-effectiveness of renal provision in the UK. JManage Med 10:6–15, 1996

14. Rubin HR, Jenckes M, Fink NE, Meyer K, Wu AW, Bass EB, Levin NW,Powe NR: Patient’s view of dialysis care. Development of a taxonomy andrating of importance of different aspects of care: CHOICE study. Am JKidney Dis 30:793–801, 1997

15. Wuerth DB, Finkelstein SH, Kliger AS, Finkelstein FO: Patient assessmentof quality of care in a chronic peritoneal dialysis facility. Am J Kidney Dis35:638–643, 2000

Renal Failure—Fetch Some Intestine!

In 1920, in vivo dialysis as pioneered by Jacob Abel and his colleagues in 1913 was difficult andexacting to perform, because the collodion (cellulose dinitrate) membrane tubes used in theirapparatus had to be prepared fresh for each dialysis. A scientist, G. R. Love (1), of theHahnemann Hospital in Chicago, suggested and used an alternative: prepared intestine. Oneto two feet of cat, rabbit, turkey, or chicken intestine were prepared in a glass rod, with themucous membrane removed in a fashion ‘‘similar to peeling a banana.’’ This was soaked inalbumin and concentrated salt solution, and then washed. By this time being ‘‘strong andelastic,’’ they easily could be tied into the vividiffusion (dialysis) apparatus to receive theanimal’s blood with an ambient dialysate pressure ‘‘just below systolic’’ to avoid too muchdistention. Thus prepared, passage of colloids and crystalloids was possible, but the gut couldbe rendered semipermeable using picric acid. Unfortunately, during the next decade fewinvestigators wanted to do in vivo dialysis, and those that did continued to use the difficultcollodion, including Georg Haas in his first human dialyses in Giessen, Germany (1923–1926).Unknown to all these workers, ‘‘cellophane’’ had been patented by the Societe Industrielle deThaon in 1910 in France, and was available from the Visking company of Chicago (2). They hadintroduced this product as a substitute for the very material which for centuries had beenstuffed to make sausages: intestine!But Love’s idea did not entirely die. On December 3, 1946, a Parisian garcon de cafe calledMario ingested 20 g of sodium chlorate and was admitted to the Hopital Lariboisiere under thecare of Professor Maurice Derot and his assistants, Pierre Tanret and Jean-Claude Reymond.Mario survived the intense hemolysis and cyanosis caused by the poison, but developed anuria3 days later. The following evening his kidneys were decapsulated—a treatment then at theend of its dubious half-century of use (3,4) and he had an exchange transfusion. Thereafter hereceived two sessions of hemodialysis, using a method of Tanret and Reymond which‘‘employed as a semipermeable membrane guinea-pig intestine’’ joining his radial artery andbasilic vein and bathed in a bath of sterile water, in which urea appeared in quantity (5). ‘‘Thesefirst trials of an artificial kidney seemed encouraging…[but] first some practical difficulties mustbe overcome.’’ Unfortunately Mario died after 9 days of terrible illness just before anotherplanned dialysis. All the other dialysis pioneers used cellophane tubing. Thereafter Tanret andReymond devoted their talents to developing a major program of peritoneal dialysis. Derotrealized its limitations and difficulties only too well, however, and in 1949 sent another youngassistant, Marcel Legrain, to Boston to work with John Merrill to learn to use the best machineavailable at that time, the Kolff-Brigham rotating drum dialyzer.

References

1. Love GR: Vividiffusion with intestinal membranes. Med Rec October 16:649–650, 19202. Moss S: Multum in parvo: Sausage casings. Semin Dial 4:173, 19913. Moss S: Multum in parvo: A modest proposal: surgical cure of Bright’s disease. Semin Dial 2:37, 19894. Moss S: Multum in parvo: Glomerulonephritis - call a surgeon. Semin Dial 7:36, 19945. Derot M, Tanret P, Reymond J-C. Hepatonephrite hemolytique mortelle apres l’ingestion de chlorate de soude.

Essai de traitement par l’hemodilayse (rein artificiel). Bull Mem Soc Med Hop Paris 13–14:302–305, 1947

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