Medical director responsibilities regarding disruptive behavior in the dialysis center--leading effective conflict resolution.

Medical directors are directly or indirectly responsible for everything that occurs in a dialysis facility. The proposed Conditions of Coverage require medical directors to oversee the process resulting in involuntary discharges from the facility. Involuntary discharges result in high costs to the patient, family, facility and payers. Consequently, End Stage Renal Disease (ESRD) Networks oversee individual facility involuntary discharge rates. A large national survey found that involuntary discharges were due to disruptive behaviors, most commonly nonadherence to medical advice. Medical directors should create an environment designed to assure that disruptive behavior and conflict can be resolved. This is best done by using positive interventions before involuntary discharge, by developing policies and procedures that are implemented continuously and by continually teaching these principles. There are two excellent references about dialysis-related disruptive behavior and conflict resolution: (1) the Renal Physician Association's second guideline, "Shared Decision Making in the Appropriate Initiation and Withdrawal from Dialysis," and (2) The Dialysis Patient Provider Conflict Project. Both will aid medical directors meet their conflict-resolving responsibilities under the proposed, federal regulations.