3 Existing Building Blocks for Continuous Quality Improvement

3.1 Renal Association Clinical Standards
3.2 The UK Renal Registry
3.3 NHS Initiatives

3.1 Renal Association Clinical Standards

In 1991 the Renal Association published a document "Provision of services for adult patients with renal disease in the UK" which described the resources and structures necessary to achieve a 'target' annual acceptance rate for RRT of 80 pmp (ref.2). At the time it was generally assumed that quality was ingrained into patient management provided treatment fell in line with good practice based on the free exchange of scientific knowledge. Challenges included the pursuit of adequate facilities to accommodate growth and sufficient levels of staffing, not only medical and nursing but also dietetics and social work. A further priority was to secure sufficient resources for new developments such as erythropoietin.

The experience in the United Stated in the 1980s, when systematic reduction in dialysis dose was observed to contribute to high mortality in dialysis patients, eventually changed perceptions of 'assumed quality' on this side of the Atlantic (ref.22,23). A faltering European Registry (European, Dialysis and Transplant Association - EDTA) and recognition that European patients were receiving less dialysis year on year raised concerns that measurable targets would be necessary to protect patients from under treatment.

In keeping with these concerns, in 1995, the Renal Association published the 'Treatment of adult patients with renal failure; recommended standards and audit measures' (ref.24). This was followed by a second edition (1997) which aimed to broaden the evidence base for the recommendations (ref.25).

The Renal Association standards initiative not only provided a framework of measurable targets but also recommended good practice over a range of areas in renal medicine. Thereafter, individual units were able to audit their practice against the RA standards as were groups working in co-operation. A third edition of the RA Standards document is in preparation which hopefully will reflect the improving epidemiology and evidence base for the practice of renal medicine. In recent years the RA Standards have become a valuable reference for providers and commissioners.