A dietitian’s role in dialysis centers and QAPI 

According to 2020 data from the United States (U.S.) Renal Data System 2023 Annual Data Report, almost 808,000 people in the U.S. (or about 2 in every 1,000) lived with End Stage Kidney Disease – 69% on dialysis and 31% with a kidney transplant. According to the National Forum of ESRD Networks, the 18 ESRD Networks serve over 7,500 dialysis centers and over 200 transplant centers in the United States and its territories.  

As of March 31, 2025, these facilities were treating more than 516,000 patients on dialysis and more than 316,000 patients with a functioning kidney transplant. Of those patients receiving dialysis, approximately 84% receive in-center hemodialysis, 15% receive dialysis at home, and 1% receive dialysis in a nursing facility.  

Dialysis clinics may have in-center hemodialysis, nocturnal hemodialysis, home hemodialysis, and peritoneal dialysis programs. A dietitian may work full-time, part-time, or per diem in one or more clinics, depending on their assignment. Depending on the number of chairs and shifts, an outpatient renal dietitian working full-time in a dialysis center may have up to 125 patients on average under their care.   

If asking a patient at the dialysis center what they perceived the role of the dietitian to be, a few common responses may include: 

• “Teach about diet, answer questions about what to eat and not to eat.” 
• “Reviews labs once per month, more if I misbehave.” 
• “Helps with my phosphorus and PTH medications.”    

To expand on the role of the dietitian in dialysis centers, registered dietitians (RDNs) utilize a variety of materials and tools to educate patients and counsel them individually to improve labs that are not meeting the goals of dialysis.   

Fluid, nutrition, and medication support during dialysis  

Other services provided to the patient at a dialysis center include reviewing intradialytic weight gains (IDWG), discussing fluid control, assessing the patient’s nutritional status, and identifying the need for oral nutrition supplements or referring the patient for nutrition support as needed. The dietitian provides information and education on nutrition support to promote good health, best outcomes, and improve quality of life for the patient.  

As of January 1, 2025, phosphate binders are paid as a renal dialysis service under Medicare Part B. Dietitians’ roles have expanded into tracking phosphate binder prescriptions that are now being filled by either an internal pharmacy for large dialysis organizations or contracted arrangements with pharmacies for midsize to small dialysis companies.  

QAPI  

Improving patient care is an ongoing process requiring members of the interdisciplinary team (IDT), including the nephrologist, registered nurse, registered dietitian, and social worker. Per the Centers for Medicare & Medicaid Services (CMS) 2008 Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities, dialysis facilities are required to develop a Quality Assurance and Performance Improvement (QAPI) program to improve facility performance and patient outcomes. The QAPI program includes steps to develop and implement plans for improvement based on facility trends for multiple areas, as outlined by CMS.    

The nephrologist or Medical Director heads the QAPI meetings with the IDT. These meetings may also include the biomedical technician, hemodialysis technician, and the patient, their caregiver, or health care proxy.  

Identifying areas for quality improvement  

The dietitian’s role in preparing reports for the QAPI meeting requires data collection in areas of nutrition, such as albumin and potassium, and Mineral and Bone Disorder (MBD), such as phosphorus, calcium, and parathyroid hormone (PTH). Other areas where the dietitian plays an important role as a member of the IDT include anemia and fluid management.

Depending on the technology available, these reports may prepopulate the data and display data trends using graphs or other means to demonstrate areas of improvement or deficiencies for the period under review.  

Deficiencies are identified, and the data is utilized to coordinate plans for improvement in order to meet CMS goals. Other areas that affect nutritional status and patient outcomes include dialysis adequacy, infections, and hospitalizations.

The IDT discusses the various trends to identify root causes and barriers that prevent the facility from meeting goals. Solutions, interventions, and dates for follow-up are formulated into an action plan. IDT members, clinic staff, the patient, and their caregivers may be assigned tasks to complete.   

Creating a project  

There’s no single correct way to develop an action plan. Dietitians can take the lead on a variety of projects, such as managing tasks, coordinating efforts, and following up with workgroup members over the course of a month or as long as needed to achieve measurable outcomes.  

Securing team buy-in is essential, as each member will play a key role in tracking and reporting progress within their assigned responsibilities. Clearly defining tasks and consistently monitoring outcomes – including areas where things deviate from the plan – enables timely adjustments within the action plan. Ultimately, any measurable improvement in patient outcomes is a success, and the process itself offers valuable opportunities for learning and growth.  

QAPI action plan   

Each dialysis facility may have its own version of a QAPI Action Plan template. Commonly included sections:  

• Problem statement  
• Goal  
• Root causes  
• Barriers   
• Team members  
• Tasks  
• Start date  
• Estimated completion date  
• Actual completion date  
• Comments section: status, outcomes, evaluation, etc.  
• Ideas for follow-up  

Ideas for dietitian-led projects 

Within projects that dietitians lead, tasks may be assigned to other team members. Follow-up may depend on lab draw dates, goals, or indicators of improved outcomes.   

Phosphorus   

This area may require medication management, reinforcement of medication adherence, education regarding the timing of medication, tracking medication supply on hand, and identifying reasons for missed doses. Additionally, it may include renal diet education. 

Hypercalcemia and hypocalcemia  

This area may require checking medications prescribed for MBD management, meeting with the nephrologist or licensed health care provider to adjust medication therapies, and/or renal diet education.

PTH  

This area may require checking medication prescriptions, meeting with the nephrologist or licensed health care provider to adjust medication therapies, reinforcement of medication adherence in-center or at home, identifying reasons for missed doses, and education as needed.   

Hyperkalemia and hypokalemia  

This area may require checking medication and meeting with the nephrologist or licensed health care provider to adjust medication therapies and dialysate prescription. Additionally, further education on renal diet and the risks of hyperkalemia or hypokalemia may be warranted, as well as reviewing other causes of hyper- or hypokalemia.  

Improving IDWG: Fluid management  

This area may require review of target weight, ultrafiltration rate (UFR), and blood pressure.  Reinforcing fluid restrictions and education on fluid management and a low-sodium diet may also be required.  

Improving nutritional status  

This area likely targets malnourished patients based on labs, unintentional weight loss, low body mass index, decreased oral intake, and other indicators of protein-energy wasting (PEW) or malnutrition. These projects are a great opportunity for RDs to lead interventions to improve patients’ nutritional status.  

Collaboration is key in the IDT approach to optimizing patient outcomes. Success in quality improvement projects involves team members who share:  

• Common goals  
• Mutual respect  
• Open communication  
• Shared values  
• Clear professional roles  
• Principles of teamwork   

Conclusion

Dietitians play a vital role in quality improvement initiatives, and there are several areas in which dietitians can lead a QAPI project. These efforts can significantly enhance patient outcomes and quality of life. Consider initiating a discussion at the next QAPI or IDT meeting to explore potential project ideas and opportunities for collaboration. 

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References

NIH National Institute of Diabetes and Digestive and Kidney Disease. United States Renal Data System. 2023 Annual Data Report. NIH, National Institute of Diabetes and Digestive and Kidney Disease website. Accessed August 2025. https://usrds-adr.niddk.nih.gov/2023  

The National Forum of ESRD Networks. Quarterly National ESRD Census. Advocating for the organizations that monitor the quality of chronic kidney disease, dialysis and kidney transplant care in the USA. The National Forum of ESRD Networks website. Published March 31, 2025. Accessed August 28, 2025. www.esrdnetworks.org 

Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2023. US Department of Health and Human Services, Centers for Disease Control and Prevention website. Published May 15, 2024. Accessed August 2025. https://www.cdc.gov/kidney-disease/php/data-research/index.html  

ESRD Conditions for Coverage (CfCs) Final Rule Rollout Frequently Asked Questions (FAQs). Published August 28, 2008. Accessed August 2025. https://www.cms.gov/regulations-and-guidance/legislation/cfcsandcops/downloads/faqsesrdrolloutfinal082808.pdf   

CMS.gov. ESRD Quality Incentive Program. CMS website. Published June 10, 2025. Accessed August 2025. https://www.cms.gov/medicare/quality/end-stage-renal-disease-esrd-quality-incentive-program   

Hand RK, Albert JM, Sehgal AR. Quantifying the Time Used for Renal Dietitian’s Responsibilities: A Pilot Study. J Ren Nutr. 2019;29(5):416-427. doi: 10.1053/j.jrn.2018.11.007.   

ESRD Clinical Performance Measures (QPM) Project Frequently Asked Questions. Accessed August 2025. https://www.cms.gov/Medicare/End-Stage-Renal-Disease/ESRDQualityImproveInit/downloads/CPM_FAQs.pdf   

End Stage Renal Disease National Coordinating Center. Professional Module: Patient Engagement in Quality Assessment and Performance Improvement (QAPI). Accessed August 2025. https://www.qirn5.org/Files/Projects/Pro-Mod-QAPI.aspx   

CMS.gov. MLN Connects Newsletter. CMS website. Published March 25, 2025. Accessed August 2025. https://www.cms.gov/training-education/medicare-learning-network/newsletter/2025-03-25-mlnc   

Dittrich M, Deane J, Gregory N. Quality Assessment and Performance Improvement (QAPI). The National Forums of ESRD Networks website. Published August 1, 2010. Accessed August 2025. https://media.esrdnetworks.org/documents/QAPI_Toolkit_2019_0326_el.pdf  

Jadeja YP, Kher V. Protein energy wasting in chronic kidney disease: An update with focus on nutritional interventions to improve outcomes. Indian J Endocrinol Metab. 2012;16(2):246-51. doi: 10.4103/2230-8210.93743.