Month: June 2018

Extraordinary Circumstances Exception

A facility can request an exception or extension (if applicable) to various quality reporting requirements due to extraordinary circumstances beyond the control of the facility. Such circumstances may include (but are not limited to) natural disasters (such as a severe hurricane or flood), systemic problems with CMS data collection systems that directly affected the ability of facilities to submit data, or extreme circumstances preventing facilities from electronic clinical quality measure (eCQM) or electronic health record (EHR)-based reporting (e.g., extraordinary infrastructure challenges or vendor issues outside of the facility’s control). This also includes temporary closure of the facility. To request an exception or extension, facility administration must complete and submit the “ECE request form”, found here, to the ESRD QIP mailbox at In order for a facility to prevent loss of points under QIP this form must be submitted within 90 calendar days of the extraordinary circumstance following the end of the last reporting period.

Updating Notifications and Accretions in CROWNWeb

Notifications and Accretions must be updated monthly in CROWNWeb. The definitions for these records are:

Notification—a discrepancy in patient data between what CMS and the Social Security Administration (CMS/SSA) database has on record and what exists in CROWNWeb.

Accretion—a record that exists in a CMS/SSA database and believed to be ESRD, but has not been admitted into CROWNWeb as a patient. (An accretion may also occur for existing patients in CROWNWeb whose key identifiers are missing or incorrect.)

All corrections to the data must be made through CROWNWeb. When updating Notifications and Accretions in CROWNWeb:

  • All facilities (including batch submitting organizations) are responsible for correcting and maintaining their own data.
  •  New notifications and accretions should be resolved within 15 days and those that are under investigation are to be resolved within 30 days.
  • The Network is responsible for the oversight of notifications and accretions and will keep facilities informed as these issues arise for correction.
For a complete tutorial, please click here.

Considering the Best Practice of Patient Involvement in Quality Improvement

Ensuring patient involvement in every aspect of healthcare is paramount to positive health outcomes and is a best practice for improvement processes. According to the article, “Patient involvement in quality management: rationale and current status”, through involvement in their care, patients served as catalysts for broad change in the attitudes of staff by providing a motivation for wider organizational changes. These patients were able to adopt different roles across projects where they shared their experiences, helped to identify improvement priorities and developed potential solutions with the staff that had cared for them.
Click here to read more on best practices for involving patients in quality improvement.

Education: A Critical Factor in Understanding De-escalation Techniques

Health care workers have an increased risk of workplace violence compared with workers in private industry, with nurses as the most common victims, and patients as the most common perpetrators, according to an article “Aggression Management Education for Acute Care Nurses: What’s the Evidence?” Risk factors include influences such as ongoing aggressive behaviors, psychiatric disorders, substance abuse, stress/frustration/anxiety, a sense of powerlessness, perceptions that violence is tolerated, inadequate security, long wait times, and lack of awareness. The article offers great tips on how education about aggression management was successful in building confidence in areas such as situational awareness, de-escalation practices and early intervention.
Click here to learn more about de-escalation techniques as presented by Margo Halm, RN, PhD, NEA-BC in the article “Aggression Management Education for Acute Care Nurses: What’s the Evidence?” and contact your Network whenever you need further guidance on managing a difficult patient situation.

Reducing Catheter Rates By Preserving Vascular Access

Reducing facility vascular access rates has been a priority for CMS for many years. With proper and ongoing staff and patient education, patients are able to maintain healthy AV fistulas or grafts. Regular performance of the look, listen, feel check allows early detection of problems andimplementation of appropriate interventions to protect the access . The Look, Listen and Feel technique is a quick and effective way to assess a patient’s access prior to cannulation. This method can be taught to patients so that they can assess their own access on non-dialysis days. This is a simple method of monitoring that does not require any special equipment and can potential save a patient’s access. Photo source: ESRD National Coordinating Center.
For more information, click on the links below:

Understanding the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP)

CMS implemented the ESRD QIP in 2012 to promote patient health by providing a financial incentive (pay for performance) for renal dialysis facilities to deliver high quality patient care. Measurements for the 2018 calendar year, which will be reflected in the 2020 payment year, are separated into three components: clinical, safety and reporting. Dialysis facilities are required to report quality measurements to CMS. These quality measurements are made available to the public.
Additional Information about the ESRD QIP:

Living Non-Related Transplant and Paired Kidney Exchange

According to the United Network for the Organ Sharing (UNOS) nationwide, more than 120,000 people are on the waiting list for an organ transplant as of May 2018. Many face a lengthy wait for an available organ. To spare an individual patient a long and uncertain wait, relatives, loved ones, friends, and even individuals who wish to remain anonymous may serve as living donors. About 6,000 transplants each year are made possible by living donors. Two types of non-related kidney donation are:
1.  Non-directed donation. With this type of donation the donor does not name the specific person to get the transplant. The match is arranged based on medical compatibility with a patient in need. Some non-directed donors choose never to meet their recipients. In other cases, the donor and recipient may meet at some time, if they both agree, and if the transplant center policy permits it.
2.  Paired kidney exchanges. This type of donation is becoming very common and an exciting option for kidney recipient and donor pairs who are not compatible with each other. Previously, people with kidney failure who had an incompatible donor were not able to benefit from the transplant being offered to them. However, paired kidney exchange programs are having a significant impact on the expanding options of living kidney transplants. Paired exchanges are now allowing transplants to occur between incompatible donor pairs and in a few unique ways.
There are many types of living kidney donations. The Network encourages dialysis facility staff to educate patients and care givers about transplant options and provide resources to help them make informed decisions.
For more information please visit:

CDC Extends Deadline for Submission of NHSN “Agreement to Participate and Consent” form to June 15, 2018

NHSN’s stated purposes have been recently updated with new provisions for sharing data with local and territorial health departments and with the Centers for Medicare & Medicaid Services (CMS). As a result all newly enrolled facilities must accept the Agreement to Participate and Consent upon enrollment, and all currently participating facilities must accept or “re-consent” to the Agreement.
  • Currently enrolled facilities are required to accept the new Agreement to Participate and Consent electronically by June 15, 2018.
  • If a facility fails to re-consent by the deadline, its NHSN functionality will be suspended until the consent form is accepted.
  • Newly enrolled facilities must consent within 60 days of enrolling in NHSN.
  • After submitting enrollment forms, the person(s) listed as the Dialysis Component Primary Contact and the Healthcare Personnel Primary Contact must log in to the enrolled facility in NHSN.
  • On the Dialysis component homepage, the primary contact should review the electronic consent form and then check the ‘Accept’ box and click ‘Submit’.
  • For more information contact with “consent form” in the subject line or visit