Have you worked in CROWNWeb lately? If not, don’t miss out on the new End-Stage Quality Report and Systems Facility Dashboard. This dashboard will help your facility track the many important forms that are due to CMS, as well as progress with your data entry. It allows you to view the 2728 forms in three categories: New, Due, and Past due forms. The dashboard also helps facilities track:
- 2746 Forms
- Notification & Accretions
- System Discharges
- Clinical Depression Screenings
- Pain Assessments
- Form 2744
- Clinical Data
Use the EQRS Facility Dashboard to help ensure that your facility is meeting ESRD QIP requirements and achieving compliance with CMS data submission guidelines. Check out the new dashboard to see all the new features!
The Centers for Medicare & Medicaid Services (CMS) announced an extension of the deadline for 2017 First Quarter NHSN reporting to Monday, July 31, 2017, at 11:59 p.m. PT. The extension will allow facilities the opportunity to ensure data are complete and accurate in accordance with ESRD QIP reporting policy.
To read the full announcement, please click here.
The current ESRD QIP measure set is not designed to measure the quality of care provided to patients with acute kidney injuries (AKI). CMS will use only ESRD patient data to calculate the NHSN Bloodstream Infection (BSI) clinical measure, NHSN Dialysis Event reporting measure, or any other measure in the ESRD QIP for Payment Year (PY) 2019; AKI patient data will not be included in the calculations.
However, facilities are encouraged to consider reporting AKI patients on a voluntary basis for internal quality improvement efforts and Centers for Disease Control and Prevention (CDC) public health surveillance purposes. Please use the following guidelines to ensure AKI patient data are excluded from QIP scoring purposes for Calendar Year (CY) 2017 NHSN BSI data.
If you have any questions or concerns regarding the extension, please contact the CMS ESRD QIP team at firstname.lastname@example.org with “AKI” in the subject line.
If you have questions regarding how to remove patients with AKI from data reported to NHSN, please contact the NHSN helpdesk at NHSN@cdc.gov with “Dialysis” in the subject line.
Do your patients want to re-enter the work force? Do they need vocational training? The Social Security Administration’s Ticket to Work Program can help Social Security beneficiaries go to work while they keep their health coverage. Ticket to Work service providers offer Social Security disability beneficiaries (persons who receive SSI or SSDI), age 18 through 64, who want to work with free job support. Services offered may include job coaching, job counseling, training, benefits counseling and job placement. Additional information and resources to help your patients learn more about the Ticket to Work program and Social Security’s Work Incentives are available below:
Call the Ticket to Work Help Line at 1-866-968-7842/ 866-833-2967 (TTY)
The June 2016 Technical Notes, published on the Dialysis Facility Compare (DFC) website, can help to demystify quality measures (QMs) that impact facility ratings. Nine of the thirteen QMs reported on the Medicare DFC website are used to calculate the Star Rating for facilities, based on the October 2016 release date (Calendar Year 2015 data). Please educate ALL members of your staff about what these measures are and how to speak with patients and family members about their care and what these measures mean to them.
For more information, including the quality measures used in Star Rating calculation, please see: https://dialysisdata.org/sites/default/files/content/Methodology/UpdatedDFCStarRatingMethodology.pdf
When challenged with the task and responsibility of delivering high quality health care, it is also necessary to take an in depth view and analyze causation of grievances, behaviors and issues that result in patients becoming at risk to having no access to dialysis care. This can include involuntary discharge (IVD) or involuntary transfer (IVT) of a patient from a facility. Managing Disruptive Behavior by Patients and Physicians: A Responsibility of the Dialysis Facility Medical Director, published by the Clinical Journal of the American Society of Nephrology, directly speaks to the challenges and opportunities available that require collaborative efforts to uncover root causes, as well as the effectiveness of leadership at the facility level.
ESRD Networks serve as a resource to both patients and providers for grievance mitigation and conflict resolution. For assistance, please contact your local Network.
Proposed rule builds patient-centered system of care to increase competition, quality and care.
CMS has issued a proposed rule that would update payment policies for the ESRD Prospective Payment System (PPS). The ESRD PPS proposed rule is one of several for calendar year 2018 designed to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility, and innovation in the delivery of care.
The ESRD Quality Incentive Program (QIP) proposed changes are for payment years 2019, 2020, and 2021, and affect a number of key dialysis data methodologies and quality measures. The proposed rule also invites comment on how to include individuals with acute kidney injury in the ESRD QIP.
For a fact sheet on the proposed rule, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-06-29.html
The ESRD proposed rule (CMS 1674-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/
CMS has established programs and educational resources to promote the reduction of healthcare disparities in the medically vulnerable patient population. The CMS Equity Plan for Medicare aims to help healthcare practitioners take action to reduce disparities among minority populations.
“The Office of Minority Health’s (OMH) vision is to eliminate disparities in healthcare quality and access and to help all CMS beneficiaries achieve their highest level of health.” The ESRD Networks, QIO Program, and CMS have made several resources available to support these efforts.
Please click here to access resources that will help staff members better understand how to collect, measure, and reduce disparities in healthcare outcomes. Also included are success stories and best practices for reducing health disparities that can be leveraged by practitioners and care partners.
Recently, the CMS Center for Clinical Standards and Quality/Survey and Certification Group sent out the following memorandums related to the ESRD recertification surveys:
- Filling Saline Syringes at the Patient Treatment Station – ESRD facilities may not fill syringes with saline from the single dose saline bag or IV tubing connected to the patient at the dialysis station. This guideline became effective as of July 2, 2017.
- Cleaning the Patient Station – To prevent cross contamination, a dialysis station should be completely vacated by the previous patient before the ESRD staff may begin cleaning and disinfecting the station for the next patient. Patients should not be moved from the dialysis station until they are clinically stable.
- Hepatitis C (HCV) Screening Exception – All infection control recommendations developed by the CDC and referenced in the Conditions of Coverage for ESRD must be followed with the exception of HCV screening.
CMS has tasked all dialysis facilities with ensuring that clinical data is accurately entered, tracked, and reported in CROWNWeb. To assist with this process, the Network encourages all facilities to compare their internal electronic medical records (EMRs) of patient level vascular access data with what has been entered in CROWNWeb on a monthly basis (both systems should be the same). The CROWNWeb Vascular Access in Use report can be used to support data validation.
If your organization utilizes batch submission, data in your EMRs upload to CROWNWeb. If there are discrepancies between the Vascular Access in Use report and your facility’s EMRs, please follow the guidelines provided in the Vascular Access Data Cleanup in CROWNWeb to reconcile the data.
Vascular access data is a clinical indicator for the Quality Incentive Program (QIP), and errors in reporting can affect payment and, ultimately, your facility’s scoring in Dialysis Facility Compare.
The preview period for reviewing your facility’s 2016 performance data will begin July 17, 2017, when CMS will make the preview Performance Score Report (PSR) available to facilities. These reports show the performance results that CMS will use to determine if a facility will incur a payment reduction for Payment Year (PY) 2018.
For information about the PY2018 QIP process please visit: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/Downloads/PY-2018-Program-Details.pdf
During the month-long Preview Period, facilities can review their measure scores and ask CMS questions about how their scores were calculated. Facilities will also be able to submit one formal inquiry if they find or suspect an error in how their scores were calculated. To access your facility’s data visit https://dialysisdata.org and sign in using your Enterprise Identity Management (EDIM) sign in and password.
For information regarding performance year 2016, which will affect PY 2018, refer to CMS ESRD Measures Manual Version 1.0.