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Clin J Am Soc Nephrol. 2015 Aug 7;10(8):1470-5. doi: 10.2215/CJN.05220514. Epub 2014 Nov 17.

Managing Disruptive Behavior by Patients and Physicians: A Responsibility of the Dialysis Facility Medical Director.

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Nephrology Section, Chestnut Hill Hospital, Delaware Valley Nephrology and Hypertension, Philadelphia, Pennsylvania, and.
Renal Medicine Associates, Albuquerque, New Mexico.


The Centers for Medicare & Medicaid Services' Conditions for Coverage make the medical director of an ESRD facility responsible for all aspects of care, including high-quality health care delivery (e.g., safe, effective, timely, efficient, and patient centered). Because of the high-pressure environment of the dialysis facility, conflicts are common. Conflict frequently occurs when aberrant behaviors disrupt the dialysis facility. Patients, family members, friends, and, less commonly appreciated, nephrology clinicians (i.e., nephrologists and advanced care practitioners) may manifest disruptive behavior. Disruptive behavior in the dialysis facility impairs the ability to deliver high-quality care. Furthermore, disruptive behavior is the leading cause for involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. IVD usually results in loss of continuity of care, increased emergency department visits, and increased unscheduled, acute dialysis treatments. A sufficient number of IVDs and IVTs also trigger an extensive review of the facility by the regional ESRD Networks, exposing the facility to possible Medicare-imposed sanctions. Medical directors must be equipped to recognize and correct disruptive behavior. Nephrology-based literature and tools exist to help dialysis facility medical directors successfully address and resolve disruptive behavior before medical directors must involuntarily discharge a patient or terminate an attending clinician.


disruptive behavior; hemodialysis; medical director; patient

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