Month: February 2018

Data Submission in CROWNWeb for Newly Open and Pending Certification Facilities

As of January 1, 2018, new dialysis facilities can access CROWNWeb before becoming certified by their local state survey agency.  ESRD Networks now have the capability of setting up a new facility in CROWNWeb prior to a CMS Certification Number (CCN) being established.  While the new facility is waiting for certification, facility users/staff can be created in CROWNWeb, and data submission can begin at the facility level. 

If a new facility is scheduled to open, please contact the Network as soon as possible to let us know.  Timely access to CROWNWeb will ensure compliance with data submission requirements of the End Stage Renal Disease Quality Incentive Program (ESRD QIP).


Emergency Preparedness: What to Know and When to Report

Emergencies caused by severe weather or disasters can happen without warning. Transportation barriers, changes in water, loss of power, or access to supplies can critically impact dialysis treatment.  Therefore, it is important to be prepared before an emergency occurs.  In addition to routine review of disaster plans, resource management, drills, and updating contact numbers and medication records, dialysis facilities are encouraged complete the following action items to ensure continuity of care:

  • Designate in CROWNWeb a Disaster/Emergency Coordinator for your facility. Be sure to include a cell phone number.
  • Conduct a Hazards Vulnerability Assessment to determine how and when your facility might be at risk.
  • Establish a Mutual Aid Agreement with a back-up dialysis provider that will accept your patients if your facility cannot provide access to care.
  • Annually contact your local Office of Emergency Management (OEM) to communicate patient census and needs of ESRD patient care during an emergency.

Reporting Operational Status to the Network
In an emergency, the Network is required by CMS to work with Federal, State and local government agencies to assist with patient safety and ensure dialysis facilities are prioritized to be open for treatment.  Networks are also tasked with tracking the status of facility operations and patient access to care during events.  If your facility becomes inoperable or inaccessible due to an emergency, it must be communicated to the Network as soon as possible.  This improves the ability of the Network to provide current information to assist patients, the renal community, and emergency management personnel.

For questions about facility emergency preparedness requirements, resource materials, or technical assistance, please contact the Network at 203-387-9332.

Understanding the Importance of Vocational Rehabilitation for ESRD Patients

For many years, Vocational Rehabilitation (VR) and Employment Networks (EN) were thought of as programs for individuals without a disability. Today, more people with disabilities are finding out that is not true and that VR/EN is more than just about employment. In the article titled “Vocational Rehabilitation for People with Disabilities” Gloria K. Lee describes employment as a fundamental right for people with disabilities. She goes on to define VR from an intervention perspective describing the complex process of VR and the different components involved. By reading this article you will understand the importance of assisting ESRD patients in obtaining in VR/EN services to improve their quality of life.

Learn New Approaches to Healthcare Improvement Using IHI’s Framework

To support your participation in the Network’s 2018 quality improvement activities (QIAs), we invite you to review the Institute for Healthcare Improvement’s (IHI) Model for Improvement, an approach that IHI uses as the framework to guide improvement work. Developed by Associates in Process Improvement, the Model for Improvement is a simple, yet powerful tool for accelerating improvement. It is not meant to replace change models that organizations may already be using, but rather to accelerate improvement.

Learn about the fundamentals of the Model for Improvement and testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles. The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Additionally, root cause analysis (RCA) is a process widely used by health professionals to learn how and why errors occurred.

To learn more about the Quality Improvement Essentials Toolkit and view all available tools, visit

Implementation of the CDC CORE Interventions Saves Lives

The Centers for Disease Control and Prevention reports infection is the second most common cause of death and hospitalization among dialysis patients.  Hemodialysis patients have multiple and frequent exposure to healthcare environments undergoing treatment three times per week with direct access to their bloodstream via venipuncture and catheters.  Healthcare expenditures for these infections are staggering. Research has shown that the Implementation of the CDC core interventions reduces infections dramatically, saving lives and reducing healthcare costs.  Take a minute to review these interventions, by clicking here, to assure your facility is doing everything possible to be safe and save lives.

February is National Heart Month

Heart disease can often be prevented by identifying risk factors and making healthy lifestyle choices. Help ESRD patients reduce their risk. Recommend appropriate preventive services, including cardiovascular disease screening tests and intensive behavioral therapy for cardiovascular disease.

For More Information:
Preventive Services Educational Tool
Million Hearts®: Resources to help educate, motivate, and monitor your patients
Centers for Disease Control and Prevention Heart Disease website

Visit the Preventive Services website to learn more about Medicare-covered services.

Have you Completed your Annual NHSN Dialysis Event Surveillance Training?

The NHSN is an electronic tracking system for healthcare-associated infections (HAIs) that integrates patient and healthcare personnel surveillance systems managed by the CDC. To fulfill the annual NHSN training requirement, at least one NHSN user at each facility must read the Dialysis Event Protocol and subsequently take the online Dialysis Event Surveillance Training before September 30, 2018. By completing the Annual Training and passing the post-training assessment, individuals are eligible to earn continuing education credits (CE), provided they complete this process online.

CROWNWeb End Users: Upcoming ESRD QIP Data Validity and Reliability Study

The Centers for Medicare & Medicaid Services (CMS) has contracted with RELI Group to assess the reliability and validity of the Clinical Performance Measure (CPM) data entered into the CROWNWeb system and Dialysis Event data entered into the Center for Disease Control (CDC) NHSN system. RELI will be randomly selecting 335 ESRD facilities to participate in this validation effort. Of those selected, 300 facilities will be sampled to submit records pertaining to CROWNWeb data and 35 facilities will be sampled to submit records pertaining to NHSN data.

If your facility is not selected for validation, there is nothing more to do. If your facility is selected to participate in the validation you will receive a Request Letter via USPS Certified Mail. These requests are scheduled to go out in February 2018. If you are part of a Large Dialysis Organization (LDO), your corporate office may receive your request and contact you for any necessary records.

Please note: you will be required to sign for the letter; if no one is available to sign at the time of delivery, the US Post Office for your area will hold the letter until you are able to retrieve it. In this case, a notice will be left at your facility.

The Request Letter will include:

  • The list of patients sampled from your facility (maximum of 10)
  • The list of records you will need to submit
  • A thorough explanation of the submission process to ensure that all records are submitted to RELI in a secure manner

Facilities that do not respond to this request will receive a 10-point reduction in their End-Stage Renal Disease Quality Incentive Program Total Performance Score (ESRD QIP TPS).

For questions on the Upcoming ESRD QIP Data Validity and Reliability Study, contact Gladys Happi, MSN, RN, CNN, ESRD Clinical Data Lead/Deputy PM at


ESRD QIP Payment Year (PY) 2019 CROWNWeb Reporting and Attestation Deadline

The Calendar Year (CY) 2017 End-Stage Renal Disease Prospective Payment System (ESRD PPS) Final Rule requires facilities to report data into CROWNWeb before the clinical month closure.  As a reminder, all CROWNWeb reporting and attestations for the End-Stage Renal Disease Quality Incentive Program (ESRD QIP) are due at the end of the last clinical month of the reporting period.

The second reporting period for the ESRD QIP Payment Year (PY) 2019 Pain Assessment and Follow-Up and Clinical Depression Screening and Follow-Up reporting measures, and the attestation period for the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) Survey measure close on February 28, 2018, at 11:59 PM Eastern Time, which is in alignment with the December 2017 clinical month closure.

For upcoming deadline information, please see the monthly editions of the CROWNWeb Newsletter or ESRD QIP page on” href=”” target=”_blank” rel=”noopener”>ESRD QIP page on  If you have any questions or concerns, please contact the ESRD QIP team at