SUNY Downstate Parkside Dialysis Center
710 Parkside Ave.
Brooklyn, NY 11226
The following applies to any patient appearing in our QAPI:
No personal information on any patient will be discussed.
No identifying information that relates or could connect to a particular patient or a staff member shall be discussed when a patient representative is present.
Patient representatives are given first priority in QAPI and they need to share their positive and negative experiences during the preceding month.
The Nurse Manager on the floor for the shift when their patient representative is going to be present in QAPI needs to be present for the meeting. Such schedule would be made a year ahead of time.
Patient representatives are rotated every month. One representative is present from each shift in each month. So, by 8 months (M/W/F and T/T/S) all representatives would have experienced what a QAPI is all about and how important their presence is to this process.
QAPI should serve as a platform to address big issues and not minor individual and personal concerns. For that we have the grievance process. Patient representatives need to help redirect what the focus of improvement in QAPI should be that concerns patients directly.
The role of the patient representative is to voice any general comments, concerns "top of list" issues that matter to most patients on dialysis. Such issues may be related to facilities structural problems, massive late arrivals and late discharges, delays in being placed on the machines constantly, recurrent water and/or blood spills if being ignored, temperature conditions and comfort levels of patients affecting many patients chronically, chronic noise and alarm issues, chronic poor staff behavior towards them, lack of respect by staff members towards them, preferential treatment of some patients over others chronically, use of cellular phone while providing direct patient care repeatedly by any specific staff member, overall hygiene of the facility, infection control issues and staff breaking infection control rules, cleanliness of the machines, vaccination questions, lighting issues, reasons for patients refusing vaccinations, awareness of emergency preparedness, awareness of access to critical staff members in emergencies, awareness to report a change in patients contact information, education on renal diet inclusive of what a low salt, low potassium and fluid restrictive diets consist of, awareness that eating while being on dialysis is not permitted due to risk for aspiration, front desk greeting behavior, waiting room area cleanliness, temperature conditions in waiting area, foul smells in the unit, awareness that patients are not supposed to throw gloves, pads, dressings, or any solid materials down drain lines and commodes, but trash it in bins, awareness of all options for renal replacement therapies such as home dialysis, transplant listing process, transplant referral process, any particular comments about AV access follow up's and cannulation by any staff members, any input that they feel some staff are not competent, etc.
Any suggestions for further improvements that will make their visit to our facility enjoyable, calm and comfortable.
Any suggestions that they feel need more education on particularly on Insurance changes, Medicare or Medicaid rules, travel rules and requirements, etc.
Awareness what can constitutes an Involuntary Discharge process, inclusive of non-payment of co-payments, or threats to staff members and any are provider, etc.
Awareness of Health Care proxy requirements and updates as well as DNR status is needed by dialysis facilities including awareness that palliative care and end of life decisions are important and for such a referral to SUNY DMC is required. Awareness that dialysis facility cannot entirely adhere to DNR request but only when an event happens, basic CPR will still be done and patient will be transferred to a hospital, and that only the hospital can enforce the full DNR policy. This is because dialysis facility is not equipped not does it have room to store bodies and is not a morgue, and full declaration of death can only be accomplished by experts and a team in a hospital. But dialysis facilities still need a copy of their DNR forms if one had been done and it needs yearly renewal/assessment if plans change.
Patient representatives in their assigned shifts need to greet and meet new patients starting their treatments and advise them on options, transplant referral process and AV access care, resources available to them for proper diet, requirements to be adherent to dialysis sessions, and requirements that communications between them and their direct care provides must be maintained at all times even when they are hospitalized or going for any procedures.
Our unit has recently experienced some significant complications resulting from overstepped boundaries between staff and a patient. This nearly resulted in an involuntary discharge due to the ongoing behavior of the patient and will likely have serious consequences with the staff members involved.
Social workers are trained to have a strong sense of who we are with our clients and who we could be to them in spite of our actual actions or intentions; we learn about transference and counter-transference, and maintaining a helping stance at all times. We see it as the only way to keep the focus on their needs so that they can be empowered to help themselves.
I feel based on my experience in the dialysis unit that for other disciplines boundaries and professionalism may be taught or practiced as an ancillary skill rather than the core of the helping professions. I see some who have also very strong professional boundaries and others who really, really, do not. I don't know how other professions are trained, but I do know that in my own experience at the master's level, understanding one's role, function, and purpose as a social worker was the essence of the entire learning experience. The possibility of dual relationships and blurred boundaries (even with the best intentions) causing harm to a client was regularly addressed and explored during those two years post-grad. I was taught that self-disclosure and client privacy were essential to the helping relationship.
Here's two things I'd like to chew on with you all:
I'd love to hear what other social workers have to say about how you "stick to your guns" when it comes to pushing through a culture full of blurred boundaries, especially if you are also rural as is our unit. I'm holding a "discussion/Q&A" session available to all staff next month, but it isn't mandatory, so I'm concerned those most at risk of violating boundaries may not attend.
Secondly, I'm hoping this group might be another way to support each other as social workers to do what we know is right in the face of so many others in the unit pushing or crossing the limits. It's a tough job to be telling people how to behave when you are not the boss, but also tasked with being a kind of ethical conscience/patient advocate for the unit! Help and ideas on what has worked for you, or even just sharing your experiences with this would be supportive!
Thanks to all and Happy Summer!
If a patient does not come to treatment, the goal is to follow up with them to find out why. If this is a reoccurring occurrence you can devise a plan to find out the best course of action that can include -
calls to the patient, family, HCP
referrals to Adult Protective Services, Mobile Crisis, police (wellness check)
letters in writing to the patient advising concerns and Medical Director's recommended safety plan.
If the patient is missing for over 30 days time then you can consider removing them from the census, but if you have been in touch with the patient and know where they are you are not able to discharge.
If they are missing for over thirty days time and you have no idea where they are, despite all efforts -- only then can they be classified as lost.
The trial program provides a previously Involuntarily Discharged patient the ability to treat in a facility for 30 days. At the end of the 30 days the facility would advise the Network if they need more time, or if they will be accepting the patient permanently. The Network obtains approval for the program from the Department of Health prior to the patient starting at the facility.
Let me know here if you have any questions on how the program works.
A social worker contacted me asking if I had any resources related to financial assistance for patients. This website under the NCC website is a list of financial resources for patients.
Home dialysis modalities are underutilized in the USA with only 8% of patients utilizing home dialysis versus 92% being treated at in-center hemodialysis facilities. The Centers for Medicare & Medicaid Services has set a 5-year target goal for 2023 is to increase the number of patients dialyzing at home to 16%. (The 2017 NY State average was 3%)