Saudi J Kidney Dis Transpl 2022;33(1):160-167

© 2022 Saudi Center for Organ Transplantation Saudi Journal

of Kidney Diseases
and Transplantation
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Review Article

Outsourcing Dialysis Program: Implementation and Challenges

Ali Alharbi, Imed Helal, Mohammed Alhomrany, Fayez Alhejaili, Dujanah Mousa

Medical Department, Diaverum Holding AB Branch, Riyadh, Saudi Arabia

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 involved in taking care of these patients is

immensely complex and largely dependent on
The first dialysis centers established in the a highly qualified professional medical and
Kingdom of Saudi Arabia (KSA) were in nonmedical staff. The prevalence of ESKD
Riyadh in 1972 and in Jeddah in 1973.1 The treated by dialysis is around 631 cases/PMP in
steady growth of lifestyle diseases such as Saudi Arabia, and the incidence is about 142
diabetes, obesity, and hypertension has meant cases/PMP and it is expected to get higher in
that by the end of 2020, there were more than the coming years.2 A recent study has shown a
20,000 patients with end-stage kidney disease higher prevalence of chronic kidney disease
(ESKD) receiving in-center dialysis in Saudi (CKD) among relatives of dialysis patients
Arabia.2 Patients suffering from ESKD have than existing data (13.8% vs. 5.7%).5,6
higher mortality rates of 13%2 and lower The demand for dialysis treatment has
quality of life compared to patients with other exceeded supply in Saudi Arabia, which has
chronic diseases.3,4 This means that the process required the Ministry of Health (MOH) to
Correspondence to: outsource dialysis care on a fee-for-service
basis. The chronic dialysis program was first
Prof. Imed Helal, outsourced in 1994 by the Ministry of Interior
Diaverum Holding AB Branch, (Alkhawled center) and with other suppliers
Riyadh Front - Building N8, until 2013 but with limited scope and key
9435 King Khaled International Airport, performance indicators (KPIs). In 2013, MOH
Riyadh 13413–3734, Saudi Arabia. contracted multiple providers including
E-mail: [email protected] Diaverum time to provide dialysis care for
 Outsourcing dialysis program 161

6000 (50% of their MOH ESKD program Diaverum Management Team Structure in
patients) dialysis patients over a period of five Saudi Arabia
years. This contract represented a new model
of care. The scope of practice included Saudi Arabia is the largest country in the
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dialysis, supply, equipment, workforce, labo- Middle East with an enormous area of 2.15
ratory, vascular access creation, and mainte- million km2 with a large desert region, thus
nance. There was a practice committee from presenting a major logistics challenge to
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the MOH/privatization office in charge of the deliver dialysis care which entails huge
concluded contracts and regulatory compliance. resources and efforts.14-17 Hiring was another
The scope of practice and KPI provided big challenge, as there was a shortage of
standards for dialysis adequacy, workforce trained medical and nursing staff units in small
ratio, etc., to ensure the high quality of care towns and villages.
payment for performance. The outsourcing of A corporate governance structure (Figure 1)
dialysis services is a new practice in gulf with domain expertise in clinical, human
countries. Few are those studies designed to resource management, logistics, and technical
assess and examine the strategies devised to expertise was needed to fulfill the obligations
improve the dialysis quality of care.7-11 The stipulated in the contract. Procurement reliable
cost of dialysis in low- and middle-income suppliers for equipment, laboratory services,
countries has not been well evaluated.12 One of dialysis, vascular access service, etc., were
the strategic tools used to meet the cost-saving needed to ensure that the supply chains were
target in health care is outsourcing. The mean robust and maintained. The lead time for the
total cost per hemodialysis (HD) session was deliverables was somehow short with
calculated as 297 US dollars (USD) [1114 aggressive time lines to establish the state-of-
Saudi Riyals (SR)], and the mean total cost of the-art dialysis centers to deliver the highest
dialysis per patient per year was 46,332 USD and the safest quality of care.
(173,784 SR).13 Another challenge was to develop a trained
In this review, we present an overview of the staff to deliver and maintain this service,
Saudi experience, challenges, and methodo- which implied the establishment of a dedicated
logy of the implementing outsourcing dialysis curriculum capable of securing the delivery of
program, which has led to the development of high-quality dialysis care. In our institution, in
the organization service to facilitate and order to secure the delivery maintenance of a
improve the quality of care. high-quality care in this complicated logistic

Figure1. Diaverum Saudi Arabia Organization.

 162 Alharbi A, Helal I, Alhomrany M, et al
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Figure 2. Diaverum clinic organization chart in Saudi Arabia.

process, we have created an Integrated sible and accountable for the quality of
Recorded Information Management System medical care, and who oversees all the unit
(IRIMS) that made possible for us to collect employees, the routine business in the clinic,
all key performance metrics and to exploit data and the daily patient management applicable
to make the right decisions concerning the to the management of ESKD18-22 (Figure 2).
implementation of the best practices related to Clinic structures basically contain a
medicine management, patient safety, waste consultant, a nephrology specialist, a resident,
management, etc. a clinical pharmacist,23 a dietitian,24 a social
We have also built a number of accountable worker,25 and an administrative staff. All work
care units with a regional medical director, together to ensure the right performance and
which are responsible for the delivery of KPIs the good functioning of the unit.
and quality management on a quarterly basis.
The corporate strategy was not simply put in Diaverum Dialysis Centers Implementation
place to focus on clinical KPIs but also to in Saudi Arabia
develop such clinical support structures like
vascular access programs in remote parts of MOH decides on the locations of dialysis
Saudi Arabia and eventually to guarantee the centers and the number of patients. Based on
delivery of high-quality dialysis. In addition, the concluded contract, we have to build or
the strategy has an instructional role as it renovate 39 centers in different locations on
encouraged educational learning from the stages many are operational. We have to build
various professions in the clinic in order to based or renovate these centers in line with the
help educate patients and their caregivers to manual designed by MOH to set up dialysis
improve concordance with their therapies. centers in the country.26 We have established a
start-up team from all related functions
Diaverum Dialysis Center Organization in (medical, operation, human resources, and
Saudi Arabia information technology) and deployed them at
least two weeks before starting work. All
Each clinic is an accountable care unit. It is supply and equipment were tested and made
managed by a medical director who is respon- available two weeks in advance.
 Outsourcing dialysis program 163
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Figure 3. Diaverum clinics in Saudi Arabia.

We also involved experienced integration The first contract was for five years and it was
nurses in our startup clinic operation from renewed for the same span until the end of
other Diaverum countries such as Spain, 2023 with the same number of patients.
Portugal, Poland, and the United Kingdom. Currently, 4280 patients in 40 clinics (Figure
The objective was to familiarize our staff with 3) are looked after by a total staff of 1387
Diaverum way, work, and management. members, of whom 180 are doctors, 776 are
One of the key initiatives for success lies in nurses, 52 are dietitians, 52 are pharmacists,
selecting highly experienced local 54 are social workers, and 240 are nonmedical
nephrologists to start the programs. Our clinic staff (Table 1). We have built 21 clinics
objectives were very clear right from the (de novo) with the highest standards available
beginning to build the organization and to in the market, and on average, it generally
achieve the targets, as set by Diaverum. took us six months to make them operational.
Due to the growing medical need among the The rest are takeover sites (MOH facilities)
Saudi population, Diaverum has made which we had to renovate and upgrade.
enormous efforts to support the health-care By dialyzing approximately 25% of the total
mission to provide universal access to state-of- Saudi dialysis population, Diaverum has
the-art specialized health-care service across become the largest independent kidney care
the Kingdom. The establishment of Diaverum provider in Saudi Arabia.
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.
Table 1. Total medical and nonmedical staff in Diaverum in Saudi Arabia.
Job title Number Nationality % of Saudi
Doctors 190 Mixed 8%
Nurses 800 Mixed 10%
Clinical dietitians 53 Saudi 100%
Pharmacists 53 Saudi 100%
Social workers 52 Saudi 100%
Clinic admins 50 Saudi 100%
Patient assistance 200 Mixed 80%
 164 Alharbi A, Helal I, Alhomrany M, et al

Water Quality, Infection Control Measures, Council (GCC) countries is high. In center,
and Maintenance of Quality HD remains the preferred modality for the
majority of patients.27
In accordance with Diaverum regulations, we Based on previous reports of the Saudi
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completely adhere to current the Association Center for Organ Transplantation (SCOT)2 and
for the Advancement of Medical Instrumentation GCC-Dialysis Outcomes and Practice Patterns
standards for the quality assurance perfor- Study,28-33 the data over seven years since the
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mance of the devices and equipment used to outsourcing program launched have helped
treat water in dialysis centers. To comply with improve the quality of dialysis care offered,
water and dialysis fluid requirements, water which exceeds the national and GCC average.
quality measurements include chemical, elec- With improvement in access to high-quality
trolyte, and microbial levels. Documentation dialysis care, the unadjusted mortality rate
of the testing, results, and the control for water among patients has dropped regularly and the
quality have to be reviewed and approved by last MOH patient satisfaction survey results
the medical director. show that the overall patient satisfaction score
We have also created a continuing education was 95.6%. We make sure that all our dialysis
infection control program. All staff members patients are registered in SCOT and in the
have to be oriented to infection control transplant center in the region.
policies and procedures at the start of employ- The contract requires providing a high-
ment and annually. We have infection control quality dialysis that meets the international
supervisor (specialist) who continuously KPI standards for a high medical care
reviews and monitors all infections and quality.34,35 The tender was designed in a very
antibiotic usage in dialysis units. In each unit, detailed and comprehensive way. It included
we have infection control practitioner, who is KPI monitored services and was subject to
fully in charge of collecting and reporting all disincentives and penalties which was one of
infection-related issues and immunizations for the major reasons for the success of the
patients and staff. The access-related infection program in these key elements in the contract.
rate in our centers is very low. We have put In addition the IRIMS network has helped
robust systems in place to manage patients Diaverum with data-driven decision-making.
with blood-borne infections. Our staff mem- The data are deeply analyzed at the center and
bers have to wear personal protective equip- national levels to explore the trends and help
ment and have to follow infection control pro- mitigate any emerging issues to improve both
cedures when performing invasive procedures. performance and efficiency.
We have implemented the quality assessment The effective stakeholder management, on
and performance improvement (QAPI) process the one hand, and getting local domain experts,
to achieve and maintain the high quality of who understand the landscape and cultural
care in our dialysis centers. The medical dimensions of the problem we were solving,
director has the responsibility for the QAPI on the other hand, have been the key elements
and ensures that periodically done. We have of success of our program. To a large extent,
maintained clear governance systems in each this has helped us consistently outperform the
unit. All staff members have to complete targets set by MOH.
mandatory training and to be both highly Our corporate governance structure has ensured
competent and skilled in their work in the the institution of established best practices to
clinic. help Saudi Diaverum to become a performing
subsidiary of Diaverum globally (Figure 4).
Diaverum Dialysis Outcomes and Clinical Our patient-centric approach has helped much
Performance Measurement in exceeding the KPI benchmarks when
compared to our sister concerns in other
The prevalence of dialysis in Gulf Cooperation countries. For example, the rate of having
 Outsourcing dialysis program 165
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Figure 4. Average clinical performance measurement scores in Saudi Arabia (2014–2020).

CKD-MBD KPIs achieved more than 80% of staff come from. Now our d-academy is
target, anemia KPI achieved 95%, and dialysis recognized by the Saudi Commission for
vascular access KPIs achieved 85%. Health Specialties (SCHS) to certify for ALS
Diaverum AB Branch established a unique and BLS and the other related continuing
vascular access program to ensure that patients medical education courses.
receive this care locally. The establishment of Currently, our academy future is beyond
this process has helped us reduce the lead training but looking to spread the culture of
times for interventions, thus leading to better health economy and to participate actively in
vascular access care and outcomes. training and education.
Our practices and governance structures were
audited for the International Organization for Conclusion
Standardization 9001/2015, and received Joint
Commission International accreditation for our The exponential increase on prevalent HD
clinics. has necessitated new models of care to rapidly
Further work is underway in conjunction with increase the capacity to provide health care to
other MOH facilities such as referrals for other dialysis patients. Outsourcing of dialysis
services, admissions, and dispensing medi- services in KSA has helped expand capacity
cations related to other comprehensive care for and provided high-quality dialysis care. The
these patients with multiple comorbidities seven years’ experience has helped us evaluate
our care and develop efficient local appro-
d-Academy priate models of care to help us outperform
internationally set benchmarks for dialysis
The establishment of Diaverum academy has care. This has also, in collaboration with MOH
helped create a pipeline of trained staff to and SCHS, helped with capacity building to
deliver the comprehensive dialysis care. The foster local talents to guarantee the long-term
nurses selected to join our facilities should success of this program.
have at least two years of experience and a
three-month training before they indepen- Conflict of interest: None declared.
dently manage dialysis. To bridge the gap and
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