Correspondence The Role of Medical Directors in Dialysis Facilities To the Editor: Two important review articles (1,2) provide generally excellent appraisals of the perceived roles of Medical Directors in dialysis facilities in achieving aspirations in terms of quality and safety. The emphasis on the need for measurement of clinical indicators and clinical out- comes is particularly welcome in an environment of increased scrutiny and accountability. Although practice patterns differ around the world, it seems that at least in the United States, Medical Directors of dialysis facilities, have been charged with the role of implementation, maintenance and review of their safety and quality improvement programs (1). This obviously requires knowledge and employment of quality improvement techniques, application of evidence-based guidelines, and the use of relevant data. One disappointing feature of the articles is the fact that the word ‘‘research’’ appears in neither. Many of the clinical indicators are drawn from clinical practice guidelines, some of which are better evidence-based than others. For instance, virtually all of the clinical indicators for calcium and phosphate targets are derived from associative and other data and not from the more rigorous evidence base derived from random- ized controlled intervention studies and / or metanalyses. It is therefore the responsibility of clinicians / directors to provide environments in their facilities which foster further research to close the evidence-gaps and improve the quality of the evidence underpinning clinical prac- tice guidelines and quality indicators. The negative out- come of the Hemo Study (3) is a good example of why this is so important. In a quality setting, a medical director’s role should therefore in our view also include leadership in clinical research. Addressing clinical practice guideline targets is essential in any dialysis program, however, there are other aspects relating to quality care of the patient worthy of consideration, inclusion and measurement as part of any continuous quality improvement program. These include a number of quality of life factors. For example, there is evidence associating the benefits of physical exercise as a way of reducing cardiovascular risk in this patient group (4,5), and thereby improving patient outcomes. As the authors have identified, malnutrition in dialysis patients (esti- mated at 40%), results in negative impacts on sur- vival (6), but the importance of psychosocial factors and emotional well-being as predictors of effective outcomes (7) has also been demonstrated. Continuous quality improvement is also very much about implementation and audit. Implementation of clinical practice guidelines and other measures directed at improving the quality of patient care and safety and indeed about staff safety is an emerging science. There is remarkably little written about implementation research. An implementation strategy (8) successful in one institution / facility may have very different effects in another—yet there are many things that can be learned from the experiences of others. Therefore, as well as clin- ical research, we believe that implementation and quality improvement research (9) is also an imperative if we are to achieve improved patient outcomes. Promotion of this sort of activity should also fall within the leadership responsibilities of the Medical Director of a dialysis facility. As part of any quality and safety improvement strat- egy, it is our view that ‘‘research’’ should feature as one of the objectives for leaders. Judy Lowthian* and Rowan G. Walker† *Monash University, Melbourne, Australia, †NorthWest Dialysis Service, Melbourne Health, Melbourne, Australia judy.lowthian@med.monash.edu.au References 1. Gutman RA: Medical direction of dialysis – a critical leadership role. Semin Dial 20:257–260, 2007 2. Kliger AS: The Dialysis Medical Director’s role in quality and safety. Semin Dial 20:261–264, 2007 3. Eknoyan G, Beck GJ, Cheung AK, et al. for the Hemodialysis (HEMO) Study Group: Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 347:2010–2019, 2002 4. Painter P: Physical functioning in end-stage renal disease: Update 2005. Hemodialysis Int 9:218–235, 2005 5. Kutner NG, Jassal SV: Quality of life and rehabilitation of elderly dialysis patients. Semin Dial 15:107–112, 2002 6. Wolfson M: Nutrition in elderly dialysis patients. Semin Dial 15:113–115, 2002 7. Finkelstein FO, Finkelstein SH: Depression in chronic dialysis patients: assessment and treatment. Nephrol Dial Transplant 15:1911–1913, 2000 8. Owen JE, Walker RG, Edgell L, Collie J, Douglas L, Hewitson TD, Becker GJ: Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease. Int. J for Qual in Health Care 18:145–151, 2006 9. Grol R, Baker R, Moss F: Quality improvement research: understanding of science of change in health care. Qual Saf Health Care 11:110–111, 2002 Seminars in Dialysis—Vol 21, No 1 (January–February) 2008 p. 113 DOI: 10.1111/j.1525-139X.2007.00375.x 113