Role of external oversight in quality activities: accreditation, credentialing, licensure, and deemed status

There currently exist a number of organizations which provide quality oversight to the ESRD program in the United States. The state surveyors confirm that dialysis facilities comply with Medicare's conditions of coverage, but surveyor activities have traditionally followed a quality assurance rather than a continuous quality improvement (CQI) model. State surveyors focus primarily on nursing homes, so their content knowledge of ESRD quality issues may be limited. The ESRD Networks have CQI expertise on their staffs, and their quality agenda is driven by their medical review boards, whose members bring scientific and technical expertise from the provider community. The success of the Networks in achieving quality goals has been hampered by personnel and resource limitations and by inconsistent direction by the Health Care Financing Administration (HCFA). Texas has developed a dialysis facility licensure program that partners its ESRD Network and its Medicare state surveyors in quality oversight activities. This collaboration has led to improved patient outcomes and may prove to be a model for other states. Non-Medicare payers may contract with dialysis providers based on performance specifications that exceed those of Medicare's conditions of coverage. A private credentialing mechanism for dialysis facilities that satisfies the performance specifications of all payers has been proposed but, in the absence of deemed status for Medicare survey and certification activities, is unlikely to achieve widespread acceptance.