4.4 Effective Delivery - Renal Association Standards and Continuous Quality Improvement

4.4.1 Renal Association Standards

It is intended that this Kidney Alliance document should be complementary to the Renal Association's initiatives on clinical standards and audit. The Renal Association, together with the Royal College of Physicians of London, first produced a consensus statement of recommended standards and good practice for treatment of renal failure in 1995 (ref.24). This was revised and extended and its second edition was produced in 1997 (ref.25), with a third edition in preparation. The document sets out the standards for clinical practice in renal failure including end stage renal disease. It is being prepared in collaboration with the Intensive Care Society and the British Transplantation Society and includes a section on paediatric nephrology. Since it is largely a consensus document, there is a need to improve the evidence base. The Chairman and members of the Standards & Audit Subcommittee have selected key standards for inclusion in this Kidney Alliance document. They are principally the standards that are most relevant to the planning, commissioning and organisation of service provision for end stage renal disease.

4.4.2 Reporting to the UK Renal Registry

The advent of the UK Renal Registry is one of the most exciting developments of the last few years. Not only will it produce important demographic and epidemiological information, it will also provide the basis for the comparative audit of outcomes in patients with ESRF and patients established on RRT. Given the absence of a statutory reporting mechanism of demographic and outcome information in renal patients it is difficult to systematically improve the service even with accepted clinical standards and targets without employing comparative audit.

The Renal Registry should lead to quality improvements provided renal units 'sign up' to the initiative. RSCGs, with their influence over the allocation of resources, are well placed to request participation in the Renal Registry and are accorded a high priority. If 100% compliance is achieved, Britain will enjoy the same potential as a handful of European countries who already have 100% subscribed National Registries with the added benefit of automated electronic downloading of information.

4.4.3 Audit - Local and Regional

Continuous quality improvement is an important component of clinical governance in provider Trusts. The Renal Association Standards provide a framework for local audit of outcomes. Since RRT has a broad multidisciplinary base, there are great opportunities to test the effectiveness of evolving practice by clinical audit. In order to do this effectively, staffing levels in renal units needs to reflect the time necessary for audit to take place, an activity which is often labour intensive.

Since RRT was initiated, most renal units have maintained contact through sub-regional, regional or even supra-regional discussion/policy groups. Variously named Renal Interest Groups, Renal Groups and more latterly Renal Audit Groups, they typically meet several times a year to exchange ideas on management, clinical protocols and on political /strategic issues. There is now a clear opportunity for these groups to input into the RSCGs. Accurate information on activity and staffing levels on the provider side and the historical problems about their region will be well known by these groups. Hopefully regional audit will be given new impetus and authority from working in concert with the RSCG's. Such initiatives will be in keeping with recent government led initiatives for improving quality and particularly continuing professional development and the requirement for all doctors to participate in clinical audit as part of clinical governance.

4.4.4 Peer Review

Peer review takes many forms. Recently some nephrologists, in concert with the Royal College of Physicians, pioneered the 'inspection' of dialysis facilities by colleagues from another region. Given that practice in renal medicine ranges from the technical to the immunological, the composition of the visiting teams were multidisciplinary. The experience from these initial peer review visits was widely disseminated and published (ref.78). It was rewarding for both sides with significant educational spin off. Rather than feeling threatened by the inspection, the host Trust often gained a useful foothold in negotiations with purchasers if shortcomings in their service were identified.

Peer review is time consuming and expensive. Recently the Royal College of Physicians paused to reconsider these and other implications. Advisory visits could constitute one of the most powerful routes to continuous quality improvement and are in keeping with the strategic flow of Government thinking. It is likely the Renal Association and the British Renal Symposium will take this initiative forward in concert. There is now a formal peer review process taking place in Scotland which is funded by the Scottish Office.

Link to National Service Standard 4