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Abstract
The demand for dialysis treatment has exceeded supply over the last decade in Saudi Arabia in line with other countries in the region and hence the Ministry of Health (MOH) to outsource dialysis care on a fee-for-service basis. The main objective of this review article is to examine and understand the challenges and strategies devised for the successful implementation, the good operation, and the guaranteed efficiency of outsourcing dialysis program in order to achieve the set clinical performance indicators and quality standards. The outsourcing program has largely helped the MOH in Saudi Arabia to improve the adequacy of dialysis care and the quality of life of dialysis patients and might be cost-effective.
Introduction 
The first dialysis centers established in the Kingdom of Saudi Arabia (KSA) were in Riyadh in 1972 and in Jeddah in 1973.[1] The steady growth of lifestyle diseases such as diabetes, obesity, and hypertension has meant that by the end of 2020, there were more than 20,000 patients with end-stage kidney disease (ESKD) receiving in-center dialysis in Saudi Arabia.[2] Patients suffering from ESKD have higher mortality rates of 13%[2] and lower quality of life compared to patients with other chronic diseases.[3],[4] This means that the process involved in taking care of these patients is immensely complex and largely dependent on a highly qualified professional medical and nonmedical staff. The prevalence of ESKD treated by dialysis is around 631 cases/PMP in Saudi Arabia, and the incidence is about 142 cases/PMP and it is expected to get higher in the coming years.[2] A recent study has shown a higher prevalence of chronic kidney disease (CKD) among relatives of dialysis patients than existing data (13.8% vs. 5.7%).[5],[6]
The demand for dialysis treatment has exceeded supply in Saudi Arabia, which has required the Ministry of Health (MOH) to outsource dialysis care on a fee-for-service basis. The chronic dialysis program was first outsourced in 1994 by the Ministry of Interior (Alkhawled center) and with other suppliers until 2013 but with limited scope and key performance indicators (KPIs). In 2013, MOH contracted multiple providers including Diaverum time to provide dialysis care for 6000 (50% of their MOH ESKD program patients) dialysis patients over a period of five years. This contract represented a new model of care. The scope of practice included dialysis, supply, equipment, workforce, laboratory, vascular access creation, and maintenance. There was a practice committee from the MOH/privatization office in charge of the concluded contracts and regulatory compliance. The scope of practice and KPI provided standards for dialysis adequacy, workforce ratio, etc., to ensure the high quality of care payment for performance. The outsourcing of dialysis services is a new practice in gulf countries. Few are those studies designed to assess and examine the strategies devised to improve the dialysis quality of care.[7],[8],[9],[10],[11] The cost of dialysis in low-and middle-income countries has not been well evaluated.[12] One of the strategic tools used to meet the cost-saving target in health care is outsourcing. The mean total cost per hemodialysis (HD) session was calculated as 297 US dollars (USD) [1114 Saudi Riyals (SR)], and the mean total cost of dialysis per patient per year was 46,332 USD (173,784 SR).[13]
In this review, we present an overview of the Saudi experience, challenges, and methodology of the implementing outsourcing dialysis program, which has led to the development of the organization service to facilitate and improve the quality of care.
Diaverum Management Team Structure in Saudi Arabia Saudi Arabia is the largest country in the Middle East with an enormous area of 2.15 million km2 with a large desert region, thus presenting a major logistics challenge to deliver dialysis care which entails huge resources and efforts.[14],[15],[16],[17] Hiring was another big challenge, as there was a shortage of trained medical and nursing staff units in small towns and villages.
A corporate governance structure [Figure 1] with domain expertise in clinical, human resource management, logistics, and technical expertise was needed to fulfill the obligations stipulated in the contract. Procurement reliable suppliers for equipment, laboratory services, dialysis, vascular access service, etc., were needed to ensure that the supply chains were robust and maintained. The lead time for the deliverables was somehow short with aggressive time lines to establish the state-ofthe-art dialysis centers to deliver the highest and the safest quality of care.
Another challenge was to develop a trained staff to deliver and maintain this service, which implied the establishment of a dedicated curriculum capable of securing the delivery of high-quality dialysis care. In our institution, in order to secure the delivery maintenance of a high-quality care in this complicated logistic process, we have created an Integrated Recorded Information Management System (IRIMS) that made possible for us to collect all key performance metrics and to exploit data to make the right decisions concerning the implementation of the best practices related to medicine management, patient safety, waste management, etc.
We have also built a number of accountable care units with a regional medical director, which are responsible for the delivery of KPIs and quality management on a quarterly basis. The corporate strategy was not simply put in place to focus on clinical KPIs but also to develop such clinical support structures like vascular access programs in remote parts of Saudi Arabia and eventually to guarantee the delivery of high-quality dialysis. In addition, the strategy has an instructional role as it encouraged educational learning from the various professions in the clinic in order to help educate patients and their caregivers to improve concordance with their therapies.
Diaverum Dialysis Center Organization in Saudi Arabia Each clinic is an accountable care unit. It is managed by a medical director who is responsible and accountable for the quality of medical care, and who oversees all the unit employees, the routine business in the clinic, and the daily patient management applicable to the management of ESKD[18],[19],[20],[21],[22][Figure 2].
Clinic structures basically contain a consultant, a nephrology specialist, a resident, a clinical pharmacist,[23] a dietitian,[24] a social worker,[25] and an administrative staff. All work together to ensure the right performance and the good functioning of the unit.
Diaverum Dialysis Centers Implementation in Saudi Arabia MOH decides on the locations of dialysis centers and the number of patients. Based on the concluded contract, we have to build or renovate 39 centers in different locations on stages many are operational. We have to build based or renovate these centers in line with the manual designed by MOH to set up dialysis centers in the country.[26] We have established a start-up team from all related functions (medical, operation, human resources, and information technology) and deployed them at least two weeks before starting work. All supply and equipment were tested and made available two weeks in advance.
We also involved experienced integration nurses in our startup clinic operation from other Diaverum countries such as Spain, Portugal, Poland, and the United Kingdom. The objective was to familiarize our staff with Diaverum way, work, and management.
One of the key initiatives for success lies in selecting highly experienced local nephrologists to start the programs. Our objectives were very clear right from the beginning to build the organization and to achieve the targets, as set by Diaverum.
Due to the growing medical need among the Saudi population, Diaverum has made enormous efforts to support the health-care mission to provide universal access to state-ofthe-art specialized health-care service across the Kingdom. The establishment of Diaverum academy has help create a pipeline of nurses, dietitians, social workers, and pharmacists prepared to serve kidney patients in general but with an specific focus on dialysis patients.
The first contract was for five years and it was renewed for the same span until the end of 2023 with the same number of patients.
Currently, 4280 patients in 40 clinics [Figure 3] are looked after by a total staff of 1387 members, of whom 180 are doctors, 776 are nurses, 52 are dietitians, 52 are pharmacists, 54 are social workers, and 240 are nonmedical clinic staff [Table 1]. We have built 21 clinics (de novo) with the highest standards available in the market, and on average, it generally took us six months to make them operational. The rest are takeover sites (MOH facilities) which we had to renovate and upgrade.
Table 1: Total medical and nonmedical staff in Diaverum in Saudi Arabia.By dialyzing approximately 25% of the total Saudi dialysis population, Diaverum has become the largest independent kidney care provider in Saudi Arabia.
Water Quality, Infection Control Measures, and Maintenance of Quality In accordance with Diaverum regulations, we completely adhere to current the Association for the Advancement of Medical Instrumentation standards for the quality assurance performance of the devices and equipment used to treat water in dialysis centers. To comply with water and dialysis fluid requirements, water quality measurements include chemical, electrolyte, and microbial levels. Documentation of the testing, results, and the control for water quality have to be reviewed and approved by the medical director.
We have also created a continuing education infection control program. All staff members have to be oriented to infection control policies and procedures at the start of employment and annually. We have infection control supervisor (specialist) who continuously reviews and monitors all infections and antibiotic usage in dialysis units. In each unit, we have infection control practitioner, who is fully in charge of collecting and reporting all infection-related issues and immunizations for patients and staff. The access-related infection rate in our centers is very low. We have put robust systems in place to manage patients with blood-borne infections. Our staff members have to wear personal protective equipment and have to follow infection control procedures when performing invasive procedures.
We have implemented the quality assessment and performance improvement (QAPI) process to achieve and maintain the high quality of care in our dialysis centers. The medical director has the responsibility for the QAPI and ensures that periodically done. We have maintained clear governance systems in each unit. All staff members have to complete mandatory training and to be both highly competent and skilled in their work in the clinic.
Diaverum Dialysis Outcomes and Clinical Performance Measurement The prevalence of dialysis in Gulf Cooperation Council (GCC) countries is high. In center, HD remains the preferred modality for the majority of patients.[27]
Based on previous reports of the Saudi Center for Organ Transplantation (SCOT)[2] and GCC-Dialysis Outcomes and Practice Patterns Study,[28],[29],[30],[31],[32],[33] the data over seven years since the outsourcing program launched have helped improve the quality of dialysis care offered, which exceeds the national and GCC average. With improvement in access to high-quality dialysis care, the unadjusted mortality rate among patients has dropped regularly and the last MOH patient satisfaction survey results show that the overall patient satisfaction score was 95.6%. We make sure that all our dialysis patients are registered in SCOT and in the transplant center in the region.
The contract requires providing a high-quality dialysis that meets the international KPI standards for a high medical care quality.[34],[35] The tender was designed in a very detailed and comprehensive way. It included KPI monitored services and was subject to disincentives and penalties which was one of the major reasons for the success of the program in these key elements in the contract. In addition the IRIMS network has helped Diaverum with data-driven decision-making. The data are deeply analyzed at the center and national levels to explore the trends and help mitigate any emerging issues to improve both performance and efficiency.
The effective stakeholder management, on the one hand, and getting local domain experts, who understand the landscape and cultural dimensions of the problem we were solving, on the other hand, have been the key elements of success of our program. To a large extent, this has helped us consistently outperform the targets set by MOH.
Our corporate governance structure has ensured the institution of established best practices to help Saudi Diaverum to become a performing subsidiary of Diaverum globally [Figure 4]. Our patient-centric approach has helped much in exceeding the KPI benchmarks when compared to our sister concerns in other countries. For example, the rate of having CKD-MBD KPIs achieved more than 80% of target, anemia KPI achieved 95%, and dialysis vascular access KPIs achieved 85%.
Figure 4: Average clinical performance measurement scores in Saudi Arabia (2014–2020).Diaverum AB Branch established a unique vascular access program to ensure that patients receive this care locally. The establishment of this process has helped us reduce the lead times for interventions, thus leading to better vascular access care and outcomes.
Our practices and governance structures were audited for the International Organization for Standardization 9001/2015, and received Joint Commission International accreditation for our clinics.
Further work is underway in conjunction with other MOH facilities such as referrals for other services, admissions, and dispensing medications related to other comprehensive care for these patients with multiple comorbidities
d-Academy The establishment of Diaverum academy has helped create a pipeline of trained staff to deliver the comprehensive dialysis care. The nurses selected to join our facilities should have at least two years of experience and a three-month training before they independently manage dialysis. To bridge the gap and maintain a steady pipeline of trained nurses, we initially had to establish our training center overseas where the majority of our nursing staff come from. Now our d-academy is recognized by the Saudi Commission for Health Specialties (SCHS) to certify for ALS and BLS and the other related continuing medical education courses.
Currently, our academy future is beyond training but looking to spread the culture of health economy and to participate actively in training and education.
Conclusion The exponential increase on prevalent HD has necessitated new models of care to rapidly increase the capacity to provide health care to dialysis patients. Outsourcing of dialysis services in KSA has helped expand capacity and provided high-quality dialysis care. The seven years’ experience has helped us evaluate our care and develop efficient local appropriate models of care to help us outperform internationally set benchmarks for dialysis care. This has also, in collaboration with MOH and SCHS, helped with capacity building to foster local talents to guarantee the long-term success of this program.
Conflict of interest: None declared.
References 
Correspondence Address:
Imed Helal
Diaverum Holding AB Branch, Riyadh Front - Building N8, 9435 King Khaled International Airport, Riyadh 13413–3734
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/1319-2442.367809
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